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CCHC Course Application
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
MM slash DD slash YYYY
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.
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