Submit this applicationtyped or printed legibly:

  • Send completed application via mail AND email to:

Elaine Millsap Parker City of Chicago – Department of Family and Support Services

1615 West Chicago Avenue – 2nd Floor ~ Chicago, Illinois 60622

Email:

Check ONLY ONE of the programs below:

St. Augustine / City Colleges of Chicago
[ ] CDA
[ ] AAS
[ ] ECE Coursework ____I/T _____ Pre-School / [ ] Child Development Associate (CDA)
[ ] AAS – Early Childhood Education
[ ] AGS-General Studies-Health Aide
[ ] AAS Human Development & Family Studies
[ ] ESL Coursework
[ ] ECE Coursework __I/T __Pre-School
National Louis University
[ ] Director’s Credential
Erikson Institute
[ ] Infant Specialist Certificate
[ ] Parent Training: Parent is a regular volunteer in the classroom ____ Yes ____No
Full Name / Job Title / Yrs in Position
Home Address / Email Address
Name of Agency (where currently employed) / Site Phone and Extension
Agency / Site Address / Yrs of Employment in HS/EHS/PI/PFA/ChildCare
Applicant Contact Number / Parent Volunteer Tracked in COPA Volunteer Section
____Yes ____No

HS/EHS Applicant:By signing this application, I agree with the terms of The Head Start Act, Section 648A (6) (A) & (B) Service Requirements. This section indicates that individuals who receive financial assistance (from DFSS) to pursue a degree will work in a Head Start program for a minimum of three years after receiving the degree; or repay the total or a prorated amount of the financial assistance received based on the length of service completed after receiving the degree. I also understand thatI will comply with all application requirements including applying for Federal Financial (FAFSA).

PI/PFA Applicant:By signing this application, I agree to the following terms. This section indicates that individuals who receive financial assistance (from DFSS) to pursue a degree will work in a PI/PFA program for a minimum of three years after receiving the degree; or repay the total or a prorated amount of the financial assistance received based on the length of service completed after receiving the degree. I also understand that I will comply with all application requirements including applying for Federal Financial (FAFSA).

Agency Site Director: By signing this application, I recommend this candidate for the above scholarship from DFSS, and certify that this candidate works at the stated site in a Head Start and/or Early Childhood Block Grant position. I will support this candidate in their continuing professional learning if they receive this scholarship.

APPLICANT’S SIGNATURE / DATE
AGENCY / PROGRAM / SITE DIRECTOR SIGNATURE / DATE