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Supplemental Questionnaire

Last Name
First Name


**Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**



Describe your one year of experience in providing information on health care and disease prevention within the community.

Do not copy and paste from your resume. Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.


Do you possess any of the following (check all that apply)? Please either upload documentation or include it on your application in the education/license sections.

90 hour Child Care Certificate
Infant, Toddler Child Development Associate Credential
Associates Degree in Early Childhood Education

Describe your experience working in a supervised early childhood program with children aged 0-3.

This experience should be included on your application. If you do not possess this type of experience, please put N/A in the text box.

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