Staff Background Form Revised 03/2018 (Duplicate this form as needed) Education, Training and Professional Experience of Certified and Noncertified Members (Including individuals certified in other countries and in States other than New York) School: Other Name Staff Name: Known by: Signature: Date: Educational Director Administrative Director Coordinator Position: Lead/Head Teacher (3-5s only) Teacher Assistant/Teacher Aide (3-5s only) Educational Background: For Support Staff/Teacher Assistants & Aides: include highest education level completed. For Professional Staff: If degree is not final, attach all transcripts of college courses completed by individual staff member. Dates Degrees or Diplomas Credit Institution Major Field of Study (Type & Subject Area) Hours From To Teaching Certifications attach a copy of the most recent teaching certificate (In State & Out-of-State): If other than permanent certification in Early Childhood Education, a completed Study Plan must also be submitted (page 5). Date Certification Title State Issued Initial Permanent Teaching Experience with Children Under Age Six (6): include current position Dates Age Groups Name of Employer Position Held From To
Staff Background Form Revised 03/2018 (Duplicate this form as needed) Education, Training and Professional Experience of Certified and Noncertified Members (Including individuals certified in other countries and in States other than New York) School: Staff Name: Other Name Known by: Signature: Date: Position: Educational Director Administrative Director Coordinator Lead/Head Teacher (3-5s only) Teacher Assistant/Teacher Aide (3-5s only) Educational Background: For Support Staff/Teacher Assistants & Aides: include highest education level completed. For Professional Staff: If degree is not final, attach all transcripts of college courses completed by individual staff member. Institution Dates Major Field of Study Credit Hours Degrees or Diplomas (Type & Subject Area) From To Teaching Certifications (In State & Out-of-State): attach a copy of the most recent teaching certificate If other than permanent certification in Early Childhood Education, a completed Study Plan must also be submitted (page 5). Title State Date Issued Certification Initial Permanent Teaching Experience with Children Under Age Six (6): include current position Age Groups Dates Name of Employer Position Held From To
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