Early Childhood Educator Licensing Fee Evaluation Form
Please complete this form to determine your eligibility for a licensing fee review or adjustment. All questions are related to your circumstances as an early childhood educator.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Current Employment Status
*
Employed Full-Time
Employed Part-Time
Unemployed
On Leave
Other
Are you currently licensed as an Early Childhood Educator?
*
Yes
No
License Expired
Which best describes your annual gross income bracket?
*
Please Select
Under $25,000
$25,000 - $39,999
$40,000 - $54,999
$55,000 - $69,999
$70,000 and above
Prefer not to say
Have you previously received a licensing fee adjustment or waiver?
*
Yes
No
Please rate the financial hardship you are currently experiencing related to licensing fees.
*
No Hardship
1
2
3
4
Severe Hardship
5
1 is No Hardship, 5 is Severe Hardship
Indicate the factors contributing to your need for a fee review (select all that apply):
*
Low income
Job loss or reduction
Medical expenses
Family hardship
Other
How strongly do you agree with the following statement: "The current licensing fee is a barrier to my continued work as an early childhood educator."
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Please provide any additional information that may support your request for a fee review or adjustment.
Submit Evaluation
Should be Empty: