CCHC Course Application |

Read carefully before submitting:

- All questions must have complete and accurate answers to be considered.
- Answers should be concise but thorough.
- Write out acronyms.
- Submit only one application.
- If possible, do not use a phone to complete the application.
- If you have any questions, please contact Lindsey Pertet at lindsey_pertet@unc.edu

Name*

First Last

Date of Birth*

Email*

Either personal or professional. Email is the primary way you will be contacted about the course.

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Degree(s) and field of study*

List all completed degrees and field of study or major(s).

Licensure/Certification

List all that are related to health including license number if applicable.

Employer Information

Include information on who employs you as a CCHC. If you are applying to practice as an independent CCHC (not employed by an agency as a CCHC), please enter "Independent" under "Employer" below. Your employer information is not needed.

Job Title*

Name of Employer*

Work Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Work Phone*

County/Counties you will serve*

Which agency is the primary funder of your position?*

Application Questions

Why are you applying to become a CCHC?*

Describe how becoming a CCHC will help you meet your current job responsibilities.

Describe your professional experience with health and safety issues related to children in child care?*

Describe your professional experience with public health?*