Participant Application

Name: _______________________________________________________

Address: _____________________________________________________

              _____________________________________________________

Phone:  ______________________________________

Email: ______________________________       County: _______________________

School District: ________________________________________________________

License Class:     A       B1       B2       C1       C2       C3       D       Rule 3      Not Licensed

In what year did you start providing care? ______________________________________

How many children do you care for that live in Stearns County or Big Lake School District?

_____________________________________________________________________

How many children do you have total in your care? _______________________________

Through this project, you will be learning about the Second Step Curriculum, Work    Sampling and the Ounce Rating Scale.  Do you have current knowledge/experience with any of these?  If so, explain.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

What do you hope to gain from participating in this project?  ______________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Return to:  Steps to School Success

  Child Care Choices, Inc.

  2901 Clearwater Rd

  St. Cloud, MN 56301