CCHC Course Application |

Read carefully before submitting:

- All questions must have complete answers to be considered.
- Answers must be clear, concise, accurate, and thorough.
- Write out acronyms.
- Application should be submitted one time. Only one application will be considered.
- If possible, do not use a phone to complete the application.

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

Employer

If you are self-employed or plan to work independently, please write independent.

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

Describe any professional experience or knowledge you have of the health and safety issues related to children ages 0-5?

Describe your current job responsibilities or the job responsibilities for which you are preparing.

State your purpose for taking the CCHC Course and how you will use this qualification to improve the health and safety of early care and education settings in your community.

CCHC Course Application

Read carefully before submitting:

Employer Information

Application Questions

Follow this blog