Former Name, if applicable
Connect ND Student Emp ID# or *Social Security Number
*Disclosure of your SocialSecurity number is voluntary. Social Security numbers are used asindividual identification numbers for record keeping andadministrative purposes. Failure to provide either a Social Securitynumber or Connect ND student EMP ID # may delay administrativeservices and processing.
Class for which you are requesting attached credit (check one only):
EC236 Social/Emotional Development & Guidance (3 credits) -- Modules8, 9, 10, 14, 15
EC209 Learning Environments for Children (3 credits) -- Modules 1, 2,3
EC233 Pre-K Methods & Materials (3 credits) -- Modules 4, 5, 6, 7
EC238 Home, School & Community Relations (3 credits) -- Modules 11,12, 13
Module completion (check one):
Modulesfor the designated class have been completed.Modulesfor the designated class have been started but are not yet complete.
Name of military facility where training occurred:
Name of trainer:
Phone number of trainer:
E-mail address of trainer:
Documentation of ModuleCompletion: Ask your trainer to sendcopies of Air Force form, AFINT 1098, for each module connected tothe class for which attached credit is requested. These documentsshould be mailed to:
Caregiver ProgramAdvisor, Dakota College at Bottineau, 105 Simrall Blvd, Bottineau, ND 58318
Fee Payment: Students applyingfor articulated credit for classes in the Child Caregiver Servicesprogram must pay an attached credit fee of per credit by the FeePayment date listed on the campus Academic Calendar.
Mail checks or moneyorders to:
Business Office, Dakota College at Bottineau,105 Simrall Blvd, Bottineau, ND 58318.
To pay by credit card,call 701-228-5430 or pay online using Connect ND > Student SelfService.
Course Assessment &Grading: Students must complete a course-related assessment from MSU-Bottineaubefore the end of semester. This assessment, along with percentagesearned on knowledge and competency assessments for the Department ofDefense Early Childhood Training Modules will be used to calculate agrade for the course.
*Signature: Bychecking this box, you have created an electronic signature aslegally binding as your hand-written signature. Also, by checkingthis box, you acknowledge that you understand the attached creditfee payment policy, course completion expectations, anddrop/withdraw policies. You MUST check this box for the applicationform to be completed. If you have not received confirmation of yourregistration within three business days, please call StudentServices at 1-800-542-6866.