Pars Form 11-22-06

Document Sample
Pars Form 11-22-06 Powered By Docstoc
					                                                                                                       PARS Enrollment Form
                                               Missouri’s Professional Achievement & Recognition System
                                    for Early Childhood, School-Age/After-School, and Youth Development Professionals
                           OPEN Initiative • PO Box 736 • Columbia, MO 65205 • www.OPENInitiative.org
                              Phone: (573) 884-3373 • Toll free: (877) 782-0185 • Fax: (573) 884-0598

 T     hank you for participating in the Professional Achievement & Recognition System (PARS)!
      was established to track professionals’ career development and recognize educational attainment. The OPEN initiative uses
                                                                                                                                      PARS

 PARS data to report on the state of the field (e.g., average salary of professionals, average level of education). Your participation in this
 project will help to heighten awareness about workforce issues at the local and state levels. You are eligible to participate if you work
 with children and youth. Being a PARS participant has a number of benefits including:
         • Receipt of a Missouri Career Lattice certificate showing your career lattice level
         • Recognition in local and state newsletters as you move up the Missouri Career Lattice
         • The ability to track and update your education and training through OPEN’s secure, on-line system
         • Opportunities to participate in many quality initiatives

1. RELEASE STATEMENT - Please sign and date.
 I, the undersigned, hereby agree that the information provided in this enrollment form is complete and accurate and will be entered
 into Missouri’s Professional Achievement & Recognition System. I understand that the information in my file will be used for the
 following purposes:
 • The University of Missouri-Columbia may use information provided in this enrollment form to compile and publish group data
    reports, determine eligibility for University-sponsored programs, and recognize individual’s educational attainment in regional
    and state newsletters.
 • The University will provide me limited, secure access to my information through OPEN’s website using an assigned personal access code.
 • Relevant state agencies may access this information to verify my educational attainment and ongoing training and education.
 • Community partners (e.g., community partnerships or regional planning commissions) with committee approval, and my Program
    Director may access my information for the purpose of community planning to increase the quality of programs and services in the
    local area. (Note: Social security numbers will not be provided to community partners for any reason.)
 The information contained in my file will not be released to the general public.
 SIGNATURE OF APPLICANT___________________________________________ DATE (mm/dd/yy) _________________

2. GENERAL INFORMATION - DO NOT attach a resume.
  Name (Last, First, Middle Initial)


  Date of Birth (mm/dd/yy)                                                                                              Social Security Number
                                                                                                                                  XXX - X ___ - ___ ___ ___ ___
  Home Address                                                                                                          Email Address (Home)


  City                                                                                            County                                                State                                  Zip Code


  Home Phone                                                                    Secondary Phone                                                                 Home Fax
    (          )                                                                   (          )                                                                   (          )
 Gender (Check one)                          Race/Ethnicity (Check all that apply)                         White                                 Black                  Hispanic/Latino                     Pacific Islander
         Male               Female                                                                         American Indian                       Asian                  Other : ________________________
 Primary/Native Language                                                                                                Secondary Languages



3. CURRENT CHILD-RELATED EMPLOYMENT - If you work in more than one program please attach additional information.
 Current Employer (Program Name)                                                                                       Bureau of Child Care License # or DVN (if applicable)


 Start Date (mm/dd/yy)                          Work Address (Physical Location)                                                                       Email Address (Work)


 City                                                                                             County                                                State                                  Zip Code


 Work Phone                                                    Work Fax                                                         Program Type (Check all that apply.)
   (           )                                                 (          )                                                       Early Childhood               School-Age/After-School                     Youth Development
The Professional Achievement & Recognition System is a project of the OPEN Initiative and is funded by the Missouri Departments of Health and Senior Services-Bureau of Child Care, Social Services, and Elementary and Secondary Education.
                                                       The OPEN Initiative is housed at the University of Missouri-Columbia and is an equal opportunity/ADA institution.
                                                                                                                                                                                                                            [Form 12/08/06]
PARS Enrollment Form                                                                                                                                                  Post Mark Date ____________
3. CURRENT CHILD-RELATED EMPLOYMENT continued
 On average, how many hours are you paid to work per week?                                     __________ Hours Per Week

 INDICATE YOUR TITLE - Check the appropriate box. Write the average number of hours that you are paid to work per week in each position on the line.
 Check all that apply. If you indicate more than one position, the total hours should equal the total hours per week listed above.
 PROGRAM ADMINISTRATION                                                              TEACHING/DIRECT SERVICE                                                                NON-TEACHING EDUCATIONAL
 # Hours Title                                                                       # Hours Title                                                                          # Hours Title
 _____            Executive Director                                                 _____           Lead/Head Teacher                                                      _____            Curriculum Coordinator
 _____            Center Owner                                                       _____           Teacher                                                                _____            Family Advocate
 _____            Program Administrator                                              _____           Co-Teacher                                                             _____            Education Specialist
 _____            Program Director                                                   _____           Assistant Teacher                                                      NON-TEACHING SUPPORT
                                                                                                                                                                            # Hours Title
 _____            Assistant Director                                                 _____           Teacher’s Aide
                                                                                                                                                                            _____            Office Support
 _____            Site Director/Site Coordinator                                     _____           Floater
                                                                                                                                                                            _____            Cook
 _____            Home-Based Owner/Director                                          _____           Senior Group Leader
                                                                                                                                                                            _____            Bus Driver
 _____            Group-Home Owner/Director                                          _____           Group Leader/Facilitator
                                                                                                                                                                            OTHER:
                                                                                     _____           Assistant Group Leader/ Facilitator                                    # Hours  Title
                                                                                     _____           Youth Development Practitioner                                         _____   ________________________

 What age group do you work with directly? Check all that apply.                                                             Infant                            Toddler                              Preschool
       Primary/Upper Elementary                            Intermediate (Middle School/Jr. High)                             Young Adolescent (Jr. High/High School)                                N/A (Administrative)

 In a typical year (January - December) are you paid to work all twelve months?                                            Yes            No       If no, how many months are you paid to work? ___________

 How much are you paid before taxes? Select one.                                      Hourly wage: __________ /hour                              Salary: __________ /year                         N/A (Program Owner)

 Is this income your household’s sole source of income?                                       Yes             No


4. CHILD-RELATED WORK EXPERIENCE
 How long have you worked in this field in any capacity, including your current and previous employment experiences? __________ Years                                                               __________ Months

 How long have you worked in this field in an administrative capacity, including all your employment experiences? __________ Years                                                         __________ Months                        N/A


5. EDUCATION/CREDENTIALS - Your Missouri Career Lattice level will be based on the supporting documentation you provide.
 INDICATE YOUR HIGHEST LEVEL OF EDUCATION - Mark only one. Attach photocopies of transcripts or grade reports.

       Some High School                                                   1-year Certificate of Proficiency in Early Childhood Education                                           Masters degree (M.A., M.S.)
       High School Diploma or GED                                         2- year degree (A.A., A.S., A.A.S.)                                                                      Ph.D. or Ed.D.
       Some College-# credits: _________                                  4-year degree (B.A., B.S.)                                                                               Other________________________

 Do you have a Child Development Associate (CDA) Credential or a Youth Development Credential (YDC)?                                                                 Yes (Attach a photocopy)                        No

 Do you have any other professional licenses, professional certifications, or vocational certificates?                                                               Yes (Attach a photocopy)                        No


6. TRAINING DOCUMENTATION - Attach copies of training certificates and certifications.
 Have you completed the training requirement for the current calendar year?                                           Yes (Attach photocopies of trainings)                          No

 Have you completed the training requirement for the previous calendar year?                                          Yes (Attach photocopies of trainings)                          No

 Do you have a CPR certification?                                      Yes (Attach a photocopy)                       No

 Do you have a First Aid certification?                                Yes (Attach a photocopy)                       No

 Have you completed any curriculum training during your career?                                       Yes (Select all that apply and attach copies of certificates)                                  No
        Creative Curriculum                            Project Construct                              High Scope                                      Montessori Approach                            Reggio Emilia Approach
        West Ed’s Program for Infant/Toddler Caregivers                                               Advancing Youth Development                                     Other: __________________________

Thank you for enrolling in Missouri’s Professional Achievement & Recognition System! After reviewing your form, we will
contact you with more information about your placement on the Missouri Career Lattice and    ’s secure on-line system.
The Professional Achievement & Recognition System is a project of the OPEN Initiative and is funded by the Missouri Departments of Health and Senior Services-Bureau of Child Care, Social Services, and Elementary and Secondary Education.
                                                       The OPEN Initiative is housed at the University of Missouri-Columbia and is an equal opportunity/ADA institution.
                                                                                                                                                                                                                            [Form 12/08/06]