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Alabama Pathways PDR Profile Update Form
Family and Group Child Care Home
At this time, only individuals whose program is eligible to participate in Alabama Quality STARS will be placed into the Alabama Pathways Professional Development Registry (PDR). If you have questions or need assistance with completing this application, contact us via e-mail at help@alabamapathways.org or by phone at (251)473-1060.
This form is NOT used to enroll in the Alabama Pathways Professional Development Registry. This form is used by existing PDR members to update information in an already active PDR Profile. If you are unsure of your PDR enrollment status, please contact us before submitting this form.
It is not necessary to complete all sections of this form. Please indicate below the type of information you are updating in your profile, then answer the fields in that section. Only questions in the section that you are updating need to be answered, with the exception of the Identifying Information section. Fields marked with an asterisk (*)are required.
All fields in the Identifying Information section must be completed. It will delay the processing of your application if these fields are not marked.
Send copies of supporting documentation with your Profile Update Form, if applicable. Supporting documentation is not always required by Alabama Quality STARS. Refer to the Alabama Pathways PDR Enrollment and Documentation Requirements chart to determine what documentation is required at each STAR level. If additional information and/or documentation is needed, you will be notified.
If you have questions or need assistance with completing this Profile Update Form, please contact us via e-mail at help@alabamapathways.org or by phone at (251) 473-1060.
Identifying Information
Complete all fields in this section.
First Name
*
Middle Name
*
Last Name
*
Maiden Name
*
Write N/A if this does not apply to you.
Date of Birth
*
MM
/
DD
/
YYYY
Last 5 of SS#
*
Business Name
*
Personal E-mail Address
*
Primary Phone
*
###
-
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-
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What type of information are you updating in your PDR Profile?
*
Contact Information (new address, phone number, etc.)
Current Employment (new employer, site change, etc.)
Formal Education (AELG credential, CDA, etc.)
Professional Development Documentation (training certificates)
Other
Check all that apply.
Contact Information
Change of Address, Phone Number and/or E-Mail Address
Personal Mailing Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
County of Residence
Personal E-mail Address
Primary Phone
###
-
###
-
####
Cell Phone
###
-
###
-
####
Work Phone
###
-
###
-
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Current Employment Information
Change of employment and/or position, etc.
Licensee Type
Family Child Care Home
Group Child Care Home
Business Name
Business' Physical Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Business' County
Employment Start Date
MM
/
DD
/
YYYY
Are you Part-Time (less than 20 hours per week) or Full-time?
Please select
Full-Time
Part-Time
Position
Please select
Family Child Care Home Licensee
Group Child Care Home Licensee
Group Child Care Home Assistant
Other
Ages of children you are currently working with:
Infants (Birth to 12 months)
Toddlers (1 and 2 year olds)
Preschoolers (3 and 4 year olds)
School-Agers (5 to 12 year olds)
Mark all that apply.
Formal Education and Professional Development Documentation
Please upload any new documentation of DHR approved training and/or educational attainments. (.pdf documents preferred)
Alabama Early Learning Guidelines Credential
Business Administration Scale Training Certificate
This training is required for Family and Group Child Home Licensees at all STAR levels.
FCCERS Training Certificate
This training is required for Family and Group Child Care Home Licensees at all STAR levels.
CDA Credential
CDA Expiration Date
MM
/
DD
/
YYYY
Degree Diploma
College Transcript
Training Certificates
Training certificates verifying 4 clock hours of training above the Minimum Standards required annual training from an outside source are only required for individuals employed at centers/programs applying for Three, Four or Five STARS.
If you are submitting multiple training certificates, please scan ALL certificates into one file for upload.
Signature and Date
Confidentiality Agreement
I, the undersigned, have read and agree to all statements indicated in this form. I hereby agree that the information provided in this form is complete, accurate, and will be entered in the Alabama Pathways Professional Development Registry. I understand that I am responsible for information included in this application and agree to update my information with Alabama Pathways Professional Development Registry when applicable.
I understand that the information in my profile will be used for the following purposes:
1. Your information will be shared with Alabama Quality STARS and used for STAR level determination.
2. Your information will be used by Alabama Pathways Professional Development Registry for Lattice Level placement determination, recognizing individual’s education attainments (such as attainment of a Child Development Associate or Bachelor’s degree).
3. Your information will be used to compile, analyze, and publish group data reports.
Data compiled from the Alabama Pathways Professional Development Registry may be released to aid community and state planning to increase the quality and services of the early care and education community. Your name will not be released to advertisers. Information that could affect the safety and security of an individual (i.e. social security numbers, birth dates and personal addresses) will not be released to any individual or agency other than the Alabama Department of Human Resources and Alabama Quality STARS.
Signature
*
Date
*
MM
/
DD
/
YYYY
If you have questions or need assistance completing this form, please contact Alabama Pathways PDR at:
E-mail Address- help@alabamapathways.org
Phone Number - 251-473-1060
Mailing Address - 3100 Cottage Hill Road; Building 4, Suite 400; Mobile, AL 36606