2014 2015 New Horizons Application

New _____ Reapplying ____ Fall___ Spring ____ Summer _____ Technical College of the Lowcountry 2014-2015 New Horizon’s...

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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