New _____ Reapplying ____
Fall___ Spring ____ Summer _____
Technical College of the Lowcountry 2014-2015 New Horizon’s Childcare Assistance Program PARTICIPANT INTAKE APPLICATION Section I: General Information (Please Print) Name _________________________________________ Student # / SSN ______________________________ Address _______________________________________
H Phone #___________________________
_______________________________________
Daytime #___________________________
Gender: Male
Female
Ethnicity: Caucasian Other
DOB: _____________
African-American
Native American
Hispanic
Asian/Pacific Islander
________________________________________
Marital Status: Single (never been married) # of dependents (list below): _______
Married
Divorced
# in daycare: ______
Separated
Widow(er)
# in after-school care: _____
Child’s Name __________________________________ DOB ____________
M
F
Child’s Name __________________________________ DOB ____________
M
F
Child’s Name __________________________________ DOB ____________
M
F
Child’s Name __________________________________ DOB ____________
M
F
How did you hear about this program? _________________________________________________________ Section II: Educational Information Highest Educational Level: Less than HS
HS Diploma
GED
Some College
Associate Degree
List all degrees, certificates, and/or diplomas received: ______________________________________________________________________ ______________________________________________________________________ Current Student Status: Currently Enrolled
New Transfer
Readmit
Major: ___________________________________ Full-Time
Part-Time
New Student Day
Evening
Cumulative GPA: __________ Section III: Employment/Income Information Employment Status: Full-Time
Part-Time
Seeking Employment
Unemployed
If employed, provide information for current employer(s): Company Name ______________________________
Job Title ________________________________
# of Years _______
______________________________
________________________________
_______
If unemployed, provide requested information below: Years as homemaker w/no substantial job outside home: _____ Years of paid part-time employment:_____ Years of paid full-time employment:______ Please return this form to: TCL – Financial Aid PO Box 1288, Beaufort, SC 29901 or 921 Ribaut Road, Building 2, Coleman Hall. Ph: 843-470-5961. Fax: 843-525-8285
Approximate gross family income: $1 - $5,000 $15,001 - $20,000
$5,001 - $10,000
$10,001 - $15,000
$20,001 - $25,000
$25,001+
Indicate approximate income amounts from the sources below, as applicable, per month. Employment
___________ Vocational Rehabilitation ___________
AFDC
___________
Child Support ___________
Veteran’s Benefits
___________
TANF
___________
WIA Grant
Unemployment
___________
ABC
___________
___________
Social Security ___________
Pell Grant (per semester) ___________
Lottery
Work Study
___________
Food Stamps ___________
___________
Other ____________________________________ How many miles (round trip) do you drive from your home to school each day?
___________ miles
Section IV: Career Goals and Requested Services Briefly describe your career goals (what you would like to be doing five years from now) and how completion of your current program at the Technical College of the Lowcountry assist you in achieving these goals: ___________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Support Services Requested: Child/Dependent Care
Books
Transportation
Tutoring
Career Counseling
Comments: ________________________________________________________________________________ __________________________________________________________________________________________ The New Horizons – Childcare program at the Technical College of the Lowcountry is funded through the Carl D. Perkins Career and Technical Education Act of 2006 (Perkins IV). All of the information on this form is true and complete to the best of my knowledge. Any information which might be used for statistical purposes may contain my name, but will not be released to the general public. I authorize the Technical College of the Lowcountry to consult with and release any pertinent data to support services, prospective employers, and/or training personnel on my behalf. ___________________________________________________ Applicant Signature
__________________ Date
FOR OFFICE USE ONLY Approved ___
Denied ____
Comments: ______________________________________________________________
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Eligibility: Economically Disadvantaged (Students are required to meet eligibility criteria in this category to receive funds.) Check additional groups below as applicable.
Single Parent_____Nontraditional____ Disabled ____ Displaced Homemaker ___ Childcare $_________ Reviewed by: ________________________________________ Perkins Grant Coordinator/Representative
_________________________ Date
Please return this form to: TCL – Financial Aid PO Box 1288, Beaufort, SC 29901 or 921 Ribaut Road, Building 2, Coleman Hall. Ph: 843-470-5961. Fax: 843-525-8285
Technical College of the Lowcountry New Horizon’s Childcare Assistance Program CHILDCARE PROVIDER VERIFICATION FORM (Please Print)
(Circle One)
Parent Name _________________________________________ Student # / SSN _______________________ Address ___________________________________________________________________________________ Daytime # (
) ___________________ H Phone # (
Parent’s Student Status: Full-Time
Part-Time
) __________________ Day
Evening
Name of Facility: _________________________________________________________________ Contact Person: _____________________________________ Phone: (
) ________________
Address:________________________________________________________________________ Type of Facility: Family Child Care Home
Child Care Center
Please provide Federal ID #/ Registration # ______________________________
Child’s Name ____________________________________
Date of Birth _____/_____/_____
Child’s Name ____________________________________
Date of Birth _____/_____/_____
Child’s Name ____________________________________
Date of Birth _____/_____/_____
TYPE OF SERVICE Full-time daycare
M
T
W
Th
F
8am – 6pm
8am – 6pm
8am – 6pm
8am – 6pm
8am – 6pm
Part-time daycare After school care Summer care
Childcare Assistance Guidelines Childcare assistance is provided through the Technical College of the Lowcountry by the Carl D. Perkins Career and Technical Education Act of 2006 (Perkins IV). The participant is responsible for all childcare expenses incurred when the college is closed for holidays or breaks, and the balance of provider fees not paid by the Perkins IV Grant. Payments will not be made for private school tuition or for daycare (other than after school care) for children of school age. Funding is subject to change without notice. Participants enrolled at the Technical College of the Lowcountry receive not less than $10 per week, not more than $30 per week, per child, based on participant eligibility for the number of weeks enrolled each semester. Participants must submit th class attendance reports no later than the 5 of each month. Failure to provide these reports may result in non-payment by the college for childcare services. The Technical College of the Lowcountry does not endorse any child care providers. Selection of a provider is the decision of the parent and the Technical College of the Lowcountry assumes no liability for the safety, protection, or quality of care. All of the information on this form is true and complete to the best of my knowledge. I give permission to the Technical College of the Lowcountry to verify the information on this form with the childcare provider named above. _________________________________________________ Parent Signature
__________________ Date
_________________________________________________ Childcare Director Signature
__________________ Date
Please return this form to: TCL – Financial Aid PO Box 1288, Beaufort, SC 29901 or 921 Ribaut Road, Building 2, Coleman Hall. Ph: 843-470-5961. Fax: 843-525-8285