Family Child Care Credential

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Family Child Care Credential Application

Personal information

First Name*

First Name

Last Name

Aspire ID

Email*

Home Phone*

Address 1*

Address Line 1

Address Line 2

City

State

ZIP Code

Work Name and Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Current Position

Experience Attestation

Requirement for candidacy:

Two years of experience as a New York state regulated Family or Group Family Day Care Provider

Two years of experience as an employee of a New York state regulated Family or Group Family Day Care program

Please note you will need a supervisor to sign off on each individual experience.

Program Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Contact Person

First Name

Last Name

Phone

Dates of Experience and Number of Hours Per Week

Please describe your experience, including the age of the children, usual number in group, your title, responsibilities, and an estimate of the total hours you were in contact with children during this time period.

ATTESTATION: Work described here is presented accurately:

Supervisor Signature

[clear]

Use your mouse or finger to draw your signature above

Supervisor Name

First Name

Last Name

Would you like to add a 2nd Work Experience?

Yes No

Program Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Contact Person

First Name

Last Name

Phone

Dates of Experience and Number of Hours Per Week

ATTESTATION: Work described here is presented accurately:

Supervisor Signature

[clear]

Use your mouse or finger to draw your signature above

Supervisor Name

First Name

Last Name

Would you like to add a 3rd Work Experience?

Yes No

Program Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Contact Person

First Name

Last Name

Phone

Dates of Experience and Number of Hours Per Week

ATTESTATION: Work described here is presented accurately:

Supervisor Signature

[clear]

Use your mouse or finger to draw your signature above

Supervisor Name

First Name

Last Name

Would you like to add a 4th Work Experience?

Yes No

Program Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Contact Person

First Name

Last Name

Phone

Dates of Experience and Number of Hours Per Week

ATTESTATION: Work described here is presented accurately:

Supervisor Signature

[clear]

Use your mouse or finger to draw your signature above

Supervisor Name

First Name

Last Name

Applicant Attestation

All of the information enclosed with this application is true to the best of my knowledge. I understand that this application will obligate NYAEYC to maintain my file, assess my coursework and respond regarding to what is needed to complete the credentialing process. This application will be active for one year from the date of acceptance.

Signature

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Use your mouse or finger to draw your signature above

Payment

The New York State Family Child Care Credential fee is $350 for NYAEYC members and $375 for nonmembers. The fee is set up in two payments: an application fee of $100 and the assessment fee of $250 (members) or $275 (non-members) due with the portfolio. All fees are non-refundable.

Application Fee *

$100

What method of payment will you be making for the $100 Application Fee?

Credit Card EIP (Please mail in original signed award to start the assessment process) Check (Please mail to start the assessment process)

Credit Card*

I authorize the non-refundable application fee of $100 to be processed*

Yes No

I understand my application will not be processed until payment is received.

Yes No

Family Child Care Credential Application

Personal information

Higher Educational Information

Experience Attestation

ATTESTATION: Work described here is presented accurately:

ATTESTATION: Work described here is presented accurately:

ATTESTATION: Work described here is presented accurately:

ATTESTATION: Work described here is presented accurately:

Applicant Attestation