Early Childhood Education Program Clearance Request Form

Early Childhood Education Program Clearance Request Form
Full Name*

First NameMiddle NameLast Name
Maiden Name
Only list previous official surnames.
Other Names Used
List other names you've used to obtain employment.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Mid Mich Email*
example@midmich.edu
Date of Birth*

MonthDayYear
Race*

American Indian or Alaska NativeAsianBlack or African AmericanHawaiian/Pacific IslanderHispanicWhitePrefer to Self-Describe
If you chose to self-describe your race, enter your response below.
Sex Assigned at Birth*

MaleFemale
Gender*

MaleFemaleNon-Binary/Third GenderPrefer to Self-Describe
If you chose to self-describe your gender, enter your response below.
Please select the goal or goals you hope to achieve.*

I've taken an Early Childhood Education course through my high school and hope to further my education in the field.I need to obtain ECE credit hours as required by my employer.I need to obtain 120 training hours in preparation for the Child Development Associate Credential (CDA)I plan to earn Mid's 1-Year Early Childhood Education Training Credential.I plan to earn Mid's 2-Year Early Childhood Education Associate Degree.I am taking courses at Mid as I prepare to transfer to a 4-Year college or university.
When do you hope to achieve your academic goals at Mid?*
Choose the semester you are planning to complete work toward your goals at Mid.
Are you currently employed in the Early Childhood Education field?*

YesNo
What age group are you working with?
What is your current hourly wage/salary?
Each of Mid Michigan College's Early Childhood Education (ECE) students is required to pass the following requirements before lab hours can start
- TB test (current within 12 months)
- DHHS Central Registry Clearance (current within two years)
- ICHAT (criminal history) search
- National Sex Offender Registry (NSOR) search
Students are responsible for completing the DHHS-1929 Form. The ECE Director will perform Michigan ICHAT and NSOR checks at no cost to the student.

The following registry checks are required if the student has resided out of state in the past five (5) years
- State Criminal History Registry Check
- State Child Abuse/Neglect Registry Check
The Michigan DHHS Central Registry Check and Michigan State Police ICHAT do not provide information for other states. It is the student’s responsibility to obtain forms from all receiving states and pay any fees associated with the checks. Students must provide Mid Michigan College's ECE Director with copies of the background checks performed.

Mid Michigan College does not reimburse the student for the cost of getting out-of-state background checks.

By signing this form, I give permission for the Mid Michigan College
ECE Director to conduct criminal history (ICHAT) and National Sex Offender Registry (NSOR) background searches for the purpose of the ECE fieldwork/lab site course requirement.
Upload a photo of the front and back of your driver's license.*

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Signature*

Clear
Date*

MonthDayYear
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In its commitment to providing a safe environment, Mid Michigan College actively endeavors to broaden our diversity, promote equal opportunity, and prohibit any form of discrimination in its programs, activities, and conditions of admission or employment. Learn more about these efforts and policies by visiting midmich.edu/eeo, midmich.edu/titleix, and midmich.edu/securityreport.
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