MARYLAND DEPARTMENT OF HUMAN RESOURCES

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					             MARYLAND STATE DEPARTMENT OF EDUCATION                                         Check One:
                         Office of Child Care                                               ____ First Application
                  Application for Continued Training Approval                               ____ Renewal

This form is to be completed by the person responsible for a training program within an Organization, Corporation,
Association, Agency or by an Individual. Send the completed form and all supporting documentation to the Office of Child
Care – Credentialing Branch, 200 West Baltimore Street, Baltimore, MD 21201.

Individual/Organization Name:________________________________________________________________________

If an Organization, Contact Person:______________________________________ Title:_________________________

Mailing Address:___________________________________________________________________________________

Daytime Phone #:_(________)___________________________ FAX #:_(_________)____________________________
                            All Applicants Read and Sign This Section For Each Application Type
  The Individual/Organization named above agrees to:
1. Provide a complete training proposal for each workshop to the OCC – Credentialing Branch prior to advertisement
   and presentation.
2. Offer training in accordance with OCC approval.
3. Maintain records of training provided, including:
A. The title and date of the workshop/seminar,
B. Brief synopsis,
C. Number of clock hours, and
D. Copies of evaluation and workshop sign-in sheets.
4. Based on successful completion – Issue a certificate or statement of completion to each participant, which
   includes the workshop title, date, name of trainer/organization, number of clock hours, approval number,
   participants name, core of knowledge area, signature of approved individual or organization representative.
5. Provide to the OCC, a quarterly report of training activities.
6. Adhere to the established business practices as submitted to the OCC.
7. Abide by the current code of ethical standards for approved trainers/organizations.
8. Provide all required information and documentation for first, renewal and new or revised training applications.
IN ORDER TO BE RECOGNIZED AS AN APPROVED PROVIDER OF TRAINING TO REGULATED CHILD CARE
PROVIDERS, I ACKNOWLEDGE THAT I HAVE READ THE ABOVE REQUIREMENTS AND AGREE TO COMPLY WITH
THEM.

______________________________________                       __________________________________ _____________________
Signature of Person Responsible for Program                      Title                           Date

  All individuals applying for approval complete the following section: (First Application Only – Unless there are changes)
1. I am a child care center provider. __No __Yes, Name of Center________________________________________,
   Position________________________________
2. I am a family child care provider. __No __Yes (attach copy of registration)
3. Did you complete high school? __No __Yes (attach copy of diploma, GED certificate, or transcript)
4. Did you attend college? __No __Yes, Number of credits earned_______________ (attach copy transcript)
5. Did you earn a degree? __No __Yes, Year_______, Name of School_____________________________________
   Major_____________________ Degree Earned________________________ (attach copy of degree/transcript)
6. Do you have experience working directly with groups of children? __No __Yes (attach copy of resume and
   documentation from each employer that states the number of hours worked, the ages of the children worked
   with, the position and length of time worked.)
7. Do you have other experience that qualifies you to provide the proposed training? __No __Yes (attach copy of
   resume and supporting documentation)
I hereby affirm that the above information given by me is true and complete to the best of my knowledge and
belief. I further affirm that all attached documents are authentic and reflect true and accurate information.

                                                           __________________________________________ ______________
                                                           Signature                                      Date
                                 DO NOT SUBMIT WITHOUT ALL REQUIRED DOCUMENTATION
OCC 1295 (Revised 07/05) – All previous editions are obsolete.
                     MSDE – Office of Child Care
            200 West Baltimore Street ● Baltimore MD 21201                           Check One:
                                                                                     ____First Application
          TRAINING PROPOSAL DESCRIPTION                                              ____Change
            Submit one proposal description form for each training.

1. Individual/Organization:___________________________________________________________
2. OCC Approval Number:___________________________________________________________
3. Contact Information: Name:________________________________________________________
   Daytime Phone___________________________ E-mail_________________________________
4. Training Title:___________________________________________________________________
5. Presenter(s):___________________________________________________________________
6. Select the Core of Knowledge subject area that will identify the major focus of this training.
   Contact the Office of Child Care – Credentialing Branch for information on how to complete this
   section for training covering more than one content area.
         Continued Training                       Core of Knowledge Training
                Content Area(s):                                       Content Area(s):
                                      #hrs                                    #hrs                           #hrs

       Child Development                        Child Development                    Special Needs
       Age-Appropriate Activities               Curriculum                           Professionalism
       Business Practices                       Health, Safety, Nutrition            Community
6. Brief description of the training (Two to Three Sentences):________________________________
   ______________________________________________________________________________
   ______________________________________________________________________________
   ______________________________________________________________________________
   ______________________________________________________________________________

8. Attach the following information with this completed form for each training:
       Training objectives (3 or more)
       A detailed lesson plan, including information on how the following aspects are addressed
          in the training: special needs, ADA, inclusionary practices, cultural sensitivity and diversity.
       Current Bibliography
       A copy of each handout
       Assessment or statement of assessment for this specific training
       Statement of the requirements for successful completion
       A copy of the certificate issued to participants for this specific training
       A copy of the evaluation form (unless generic and previously submitted)

                           Incomplete training proposals will be returned.

Revised May 31, 2006

				
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