Early Childhood Education Program Application

Early Childhood Education Program Application
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 plan to start taking courses at Mid?*
Choose the semester you plan to begin taking courses at Mid.
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.
Each of Mid Michigan College's 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 obtaining a DHHS Central Registry Clearance letter and TB test. The ECE Coordinator will perform Michigan ICHAT and NSOR checks at no cost to the student. The TB testing fee is the student’s responsibility and will not be reimbursed by Mid Michigan College.

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 Program Coordinator with copies of 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
Early Childhood Education (ECE) Program Coordinator to conduct criminal history (ICHAT) and National Sex Offender Registry (NSOR) background searches for the purpose of the ECE fieldwork/lab site course requirement.
Signature*

Clear
Date*

MonthDayYear
Significant effort has been made to ensure this content meets accessibility guidelines. If you encounter a barrier you can report the barrier at midmich.edu/reportaccessibilitybarrier or contact Academic Affairs at (989) 386-6603 or academics@midmich.edu.

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, midmich.edu/securityreport.
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