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Membership Info
Application
1. APPLICANT INFORMATION:
Date of Application:
(Required)
MM slash DD slash YYYY
County of Residence:
(Required)
Providence
Kent
Bristol
Washington
Newport
County Where You Work:
(Required)
Providence
Kent
Bristol
Washington
Newport
Full Name (as shown on your income tax return):
(Required)
First
Middle
Last
Previous/Maiden Name (if applicable):
Last
Address:
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone:
Cell Phone:
(Required)
Email Address:
(Required)
Date of Birth:
(Required)
MM slash DD slash YYYY
Gender (optional):
Male
Female
Prefer Not to Answer
Ethnicity (optional):
American Indian or Alaska
Native Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Pacific
Islander
White
Two or More Races
Other
Preferred Language:
Spanish
English
Other
2. EDUCATION BACKGROUND
Degree(s) Earned (check all that apply):
(Required)
Current CDA Credential
Coursework completed but no degree earned
Associate’s degree
Bachelor’s degree
Master’s degree
Coursework Major
Coursework College Attended
Associate's Major
Associates College Attended
Year Graduated
Bachelor's Major
Bachelor's College Attended
Year Graduated
Master's Major
Master's College Attended
Year Graduated
Have you completed any additional education that is not listed above?:
(Required)
Yes
No
If yes, please explain:
How will you submit your official transcript?:
(Required)
Emailed to
[email protected]
directly from the school
Mailed to WAGE$ (501 Centerville Road Suite 202) directly from the school
I will drop off the transcript in a school sealed envelope to WAGE$ (501 Centerville Road Suite 202)
CDA Only: I have attached a copy of the certificate from the Council below.
Upload a copy of the certificate from the council:
Max. file size: 128 MB.
Have you or are you currently participating in:
(Required)
TEACH
LearnERS
Rhode Island Early Childhood Registered Apprenticeship
I have not participated in, nor am I currently participating in, those programs.
3. OWNERSHIP STATUS
Ownership Status:
(Required)
I own my own Family Child Care Business and work as an educator/operator. I do not own any other child care business.
I own or am listed as an office holder with more than one Family Child Care Business. I have listed them below.
I am employed by my child care program. I do not own any child care facilities.
Supervisors Name
(Required)
First
Last
If you are the owner, you are authorized to enter your name here.
Supervisors Email:
(Required)
If you are the owner, you are authorized to enter your name here. **Please ensure this email is accurate or we will not be able to process your application!**
Date you became owner:
MM slash DD slash YYYY
Single Family Child Care Home
Max. file size: 128 MB.
Verify your income by submitting Schedule C from your most recent tax return. Please upload above.
Please list site names here:
Multiple Site Ownership:
(Required)
Drop files here or
Select files
Max. file size: 128 MB.
Verify your income by submitting your most recent 1040 Tax Form, all supporting schedules and the W2 Form (if you file jointly, the W2 forms from both parties must be submitted). Additional business documents may be requested if necessary. Please upload above.
No Ownership:
(Required)
Max. file size: 128 MB.
Verify your income by submitting documentation of your pay rate such as a recent paystub. Please upload above.
Child Care WAGE$ RI requires all applicants to be registered with the Rhode Island Start Early System (RISES).
Enter Your Workforce ID:
(Required)
Verify your registration:
(Required)
Max. file size: 128 MB.
Verify your registration by submitting a downloaded copy/screenshot of your registry profile. This must include your Workforce ID. Please upload below.
5. PARTICIPATION AGREEMENT
By signing below you agree to the
full agreement here
Signature
(Required)
