Teacher Licensure Unit (TLU)

Early Educator Support, Licensure and Professional Development Unit (EESLPD)

ENROLLMENT & CHANGE FORM

Early Childhood Education Teachers - Nonpublic Schools

INSTRUCTIONS TO ENROLL

Early Childhood Education lead teachers who work in nonpublic schools (Child Care Centers, Developmental Day, and Head Start programs) are required to enroll with the EESLPD Unit. Teachers must hold one of the following degrees and/or teaching licenses.

· BA/BS degree in any field (attach or have college/university mail official transcripts) to be considered for a NC Lateral Entry B-K License

· NC Birth-through-Kindergarten (BK) or Preschool Add-on License (Professional Standard I or II)

· Other NC Teaching License (field other than BK) or another State’s License/Certificate

A Glossary of teacher education and licensure terms is located at::

http://ncchildcare.dhhs.state.nc.us/pdf_forms/NCPre-K_Glossary.pdf

The Enrollment-Change form must be used to enroll initially and to update your information when needed:

1. Complete the Enrollment-Change Form (pages 2-4) - (A) Download the form to your desktop. (B) Type in the shaded fields. (C) Enter your legal name as it appears on your Social Security card. (D) Print and sign. (E) Attach required documents. (F) Give the packet to your site administrator to review and verify that all documents are complete and attached. (G) Submit your enrollment packet via certified mail to:

Early Educator Support, Licensure and Professional Development Unit

DHHS - Division of Child Development and Early Education

2201 Mail Service Center - Raleigh, NC 27699-2201

Attention: Fay Lewis, Licensing and Policy Consultant

2. Please keep a copy for your records. Give a copy to your Site Administrator and, for NC Pre-K Teachers only: also give a copy to your local NC Pre-K Contract Administrator and/or NC Pre-K Program Contact. Your enrollment form will be processed when all requested information and documentation is included. Incomplete enrollment forms will be returned.

3. Upon receipt of your Enrollment-Change Form, the EESLPD Unit will:

A. Confirm receipt of your enrollment and communicate instructions for next steps.

B. Determine and prioritize your eligibility and readiness status to participate in the

· Lateral Entry Teacher Program [LETP] - teachers without a B-K SPI or a SPII license

· Beginning Teacher Support Program [BTSP] - teachers with a B-K SPI, Preschool Add-On, or a Lateral Entry license

· Licensure Renewal Program - teachers with a B-K or Preschool Add-on SPII license

C. Inform you, your site administrator, and if applicable the local NC Pre-K contract administrator about the required professional development series: Orientation and NC Teacher Evaluation Process, Developing Smart Goals and Professional Development Plan, and McREL Online Educator Evaluation System.

D. Facilitate the licensure application process, if you have less than a B-KSPII, or qualify for renewal or another licensure action.

E. Contact your higher education advisor, if you are currently working with a university to complete B-K licensure. Lateral Entry candidates (less than a B-KSP I) must provide their advisor’s contact information on the Enrollment-Change form.

F. Provide mentoring support-supervision, conduct teacher observations and facilitate development of teacher Professional Development Plans based on licensure level.

Information about the program, requirements and processes will be discussed at Orientation and is posted on the DCDEE website: http://ncchildcare.dhhs.state.nc.us/general/mb_ncprek_detail.asp.

For assistance and questions, please contact Fay Lewis, EESLPD Unit Licensing and Policy Consultant , Sharon Spigner, EESLPD Unit Education Consultant at , or Anne-Marie deKort-Young, EESLPD Unit Race to the Top BK Project Coordinator .

FINAL 5.10.12

EESLPD Enrollment and Change Form – Nonpublic Schools

Mark one: Initial/First Enrollment Changes to my information (highlight your new information)

I am: NC Pre-K Teacher in Nonpublic School Other Teacher in Nonpublic School

(check your program in Section II) (check your program in Section II)

I teach: Infants/Toddlers Preschoolers

Section I- Teacher Information (tab from field to field)
Write your full legal name as it appears on your Social Security card:
First Name: Middle Name: Last Name: Social Security Number:
Home Mailing Address: City: Zip Code: Date of Birth w/year:
Ethnicity: Black Native Hawaiian /Other Pacific Islander Asian American Indian /Alaska Native White
Hispanic? Yes No Gender: Female Male
Home Phone Number: Cell Phone Number:
E-Mail Address: County (your home location: )
Section II- Site Information (double click in check boxes and select “checked” under default value)
Yes, I am employed in Private Child Care Center Head Start Developmental Day.
Complete all sections as they apply to you and have Site Administrator/Director complete Section VI.
No, I am not employed in any of these programs, but work in a public school.
Do not complete this form but contact your Local Education Agency (school system).
Program Site Name: DCD Star Rating:
Site Administrator/Director Name: Site County:
Site Physical Address: City: Zip Code:
Site Admin E-Mail Address: Site Phone Number: Site Fax:
Section III- Education and Licensure Information (B-K or Preschool Add-On License)
Degree: BA/BS MA/MS EdD/PhD Major:
University/College:
Do you hold: NC Teacher/Educator’s License? Yes or: Other State’s Teacher’s License
If you checked a box above, please attach a copy of your license.
No, I do not hold any Teacher/Educator’s License. Move to Section IV.
If you hold a license, have you completed a Beginning Teacher Support Program (BTSP)? Yes No
If yes, attach your most recent Teacher Evaluation Summary Rating Form and Professional Development Plan.

CONTINUE ON NEXT PAGE……

Section IV- B-K Licensure Status (Less than a B-K or Preschool Add-On License)
If you do not have a B-K License are you enrolled in an accredited B-K licensure program with a College or University/ Institute of Higher Education (IHE)? Yes No
If yes, what is the name of the School: and IHE Advisor: Phone Number:
Are you affiliated with a NC Department of Public Instruction Regional Alternative Licensing Center (RALC)?
Yes No If yes, RALC Region: Site Coordinator: Phone Number:
Do you have a Plan of Study or Licensure Only Plan? Yes (attach a copy) No
If yes, have you completed all of the required coursework in your Plan of Study/Licensure Only Plan? Yes No
If no, how many semester hours do you need in order to complete your Plan of Study or Licensure Only Plan?
Do you currently have a T.E.A.C.H.® Scholarship? Yes No
Are you receiving a WAGE$® Supplement? Yes No
Section V- Professional Development (Mandatory)
I have completed Foundations: Early Learning Standards (Training completed prior to January 2007 will be accepted.) Yes Attach a copy of your certificate.
No Complete training at this link: www.earlylearning.nc.gov/Foundations/OnlineTrainingTool.asp
After you receive your certificate, please submit a copy to the EESLPD Unit.

Teacher’s Signature Date

Submitted to Site Administrator on ____Date Submitted to Local NC Pre-K Contractor, if applicable, on ____Date
Your Site Administrator must review and verify that all documents are complete and attached by completing the next page. Once reviewed and signed, mail all documents by certified mail to the address listed.
CONTINUE ON NEXT PAGE……
Section VI- Site Administrator – Verification of Teacher’s Documents (Mandatory)
The teacher’s Site Administrator is required to verify that all documents are included in the packet before the teacher submits to the EESLPD. By initialing sections A and C or B and C, which correspond to the Enrollment-Change Form, the Site Administrator is verifying that the teacher’s enrollment or change form and supporting documents are complete. After the Site Administrator completes her/his review, the teacher should mail the packet via certified mail to the address at the bottom of this page.
Teacher’s First Name: Middle Name: Last Name:
Section A. Education and Licensure Information (Teachers who hold a B-K or Preschool Add-On License)
Subject / Document attached / Verification by Site Administrator
(initial if documents attached)
I. BA/BS degree in any field (attach original transcripts) / · Original transcript
II. Teacher’s License / · North Carolina or
· Other State’s Teacher’s License
III. Beginning Teacher Support Program (BTSP)? Only if teacher completed a BTSP program. / · Most recent Teacher Evaluation Summary Rating Form and
· Professional Development Plan
Section B. B-K Licensure Status (Less than a B-K or Preschool Add-On License - do not hold a B-K license)
Subject / Document attached / Verification by Site Administrator
(initial if documents attached)
I. Enrolled in an accredited B-K licensure Program with a College or University / · Plan of Study or
· Licensure Only Plan
Section C. Professional Development
Subject / Document attached / Verification by Site Administrator
(initial if document attached)
I. Foundations: Early Learning Standards for Preschoolers / · Certificate for Foundations
I ______verify that I have reviewed the enrollment packet and all
Site Administrator’s Name– Please Print
required documents are attached. I understand if the packet is complete, the teacher will be placed on the EESLPD Unit wait list. Incomplete packets will be returned.

Mail all documents by certified mail to:

Early Educator Support, Licensure and Professional Development Unit

Division of Child Development and Early Education

2201 Mail Service Center

Raleigh, NC 27699-2201