PERKINS CHILD CARE ASSISTANCE APPLICATION
Check ALL that apply:
SEMESTER YEAR: 20______ SEMESTER YEAR: 20______
_____ Fall _____ Spring _____ SI _____ SII
_____Fall Late Start _____ Spring Late Start _____ Spring Mini
Please PRINT:
Name: ________________________________ ID # : _____________________________ Address:________________________________ Phone: _____________________________
________________________________ Email: _____________________________ Program of Study (Major) _______________________________
Emergency Contact: ______________________ Relationship: _______________________ Address:________________________________ Phone: _____________________________
_________________________________
Child Care Center Name _________________________________
Address: _________________________________
_________________________________
Phone # ___________________________ Contact Person ____________________________ Email: ____________________________ Fax: ______________________________ ******************************************************************************
FOR OFFICE USE ONLY File Completion:
1. _____ Current signed degree plan 2. _____ Child(ren)’s birth certificate 3. _____ Copy of current class schedule
4. _____ Financial Aid Signature or proof of financial need
Received by ______________________________ Revised 09/13 jw
PERKINS CHILD CARE ASSISTANCE APPLICATION CONTINUED
To be considered for free child care, you must meet one of the following special needs: (Check all that apply)
1.___ be single parent OR
2.___ have one or more of the following impairments, disabilities, or other conditions which may require services or accommodations in order for you to be successful in your program of study (documentation must be provided)
a. ___learning disability (e.g. dyslexia, aphasia) b. ___deaf c. ___blind
d. ___deaf and blind e. ___hard of hearing (but not deaf)
f. ___other health impairment (e.g. heart conditions, asthma, etc.) g. ___visually impaired (but not blind) h. ___speech impaired i. ___orthopedically impaired j. ___English as a second language
k. ___economically disadvantaged
AND you must meet all four requirements below (Check all that apply): 1.___ be enrolled in or declare intent to enroll in a vocational-technical program. 2.___ be enrolled and maintain enrollment in at least 6 semester hours, during Fall and Spring Semesters, and at least 3 semester hours, during Summer Sessions 3.___ have dependent child(ren) 4.___ demonstrate financial need as determined by the FAFSA
or
demonstrate financial need by providing a copy of your most recent tax return and a completed copy of the EFC calculator at http://www.finaid.org/calculators/finaidestimate.phtml
To apply for assistance, you must provide: 1. Completed application
2. Provide copies of your:
a. current degree plan signed by you and your program advisor b. child(ren)’s birth certificate
c. current class schedule
d. signed financial aid statement (from the Financial Aid Office)
or a copy of your tax return and a printed copy of the EFC calculator results.
_____ FILE _____ CHILD CARE CENTER _____ STUDENT CHILDCARE ASSISTANCE PROGRAM GUIDELINES
Please read the following guidelines carefully. Your adherence to these guidelines is required for continued participation in this program. Please initial that you have read each guideline and sign this form.
_____ All children must be pre-registered with the Galveston College Office of Special Services and the child care center. The child care center may have an additional application that must also be completed prior to the child(ren) receiving services. Participants must read and abide by the center’s published rules.
_____ You must notify both the child care center and Galveston College Counseling Center if you no longer need childcare. If your child(ren) do not attend for one week, and you do not notify the child care center and The Galveston College Counseling Center your child(ren) will be removed from the roster and the next person on the waiting list will be given the space. If you stop bringing your child(ren) without notification, your file will be flagged, and you may not be eligible for child care services in the future.
_____ The child care center may only bill for hours needed for class attendance, study time and/or clinicals. _____ You must provide the child care center and Galveston College a phone number and an emergency
contact number.
_____ Any changes to the schedule must done in writing. Change forms are available in the Galveston College Counseling Center. The child care centers will not be allowed to bill for times that are not listed on the original schedule or on a signed change form.
_____ Childcare services for study/resource lab/tutoring time (on campus only). You may add 1-2 hours of study time per class, per week, as your funding allows. Study/resource lab/tutoring time must be listed and approved on your application schedule page.
_____ In the event that a situation arises where you will not be able to pick your child(ren) up at the scheduled time, you MUST communicate the change to the day care center within one hour of the scheduled pick up time, or sooner, if possible. _____ Child care outside of normal semesters are not covered (i.e., holidays, vacations, semester breaks, etc.).
_____ Note: Additional child care costs for care provided outside of the agreed upon schedule are not covered by the Carl Perkins childcare assistance program or Galveston
I understand that day care services are subject to my attendance in class and my maintaining eligibility based on financial need. I understand that I am responsible for paying 100% of unapproved expenses, which includes day care for any period of time (i.e. holidays, spring break, etc.) when Galveston College is not in session.
I attest that I have received, read, and abide by the Day Care Program Guidelines as outlined. I further attest that all information given on my financial aid and day care application is true and correct.
I understand that I will be responsible for reimbursing Galveston College any day care funds that have been paid on my behalf as a result of provided false or incomplete information on this application.
Failure to abide by the guidelines listed above (and on opposite page) may result in suspension or termination from the program.
_____________________________________ ______________________
Student Signature Date
_____________________________________ ______________________ Galveston College Representative Signature Date
It is the policy of Galveston College to provide equal opportunities without regard to age, race, color, religion, national origin, sex, disability or veteran status. Revised 08/13/jw
_____ File Copy _____ Child Care Copy _____ Student Copy
STUDENT NAME: ________________________________ ID# _____________________ DATE: _____________ CURRENT PHONE # _________________________
CHILD INFORMATION AND SCHEDULE FORM
Please provide a SEPARATE COPY of this form to the Counseling Center for EACH SEMESTER that child care is needed. You also need to provide a stamped copy of this form to the child care center each semester.
You must turn in a COMPLETED RENEWAL FORM BY THE DEADLINE (listed in the Schedule of Classes) or YOUR CHILD’S SPACE WILL BE GIVEN TO NEW APPLICANTS and
YOUR RENEWAL APPLICATION WILL NOT BE REVIEWED UNTIL THE SECOND WEEK OF CLASSES. **If you do not know your schedule by the application due date, turn in the renewal form and attach a note stating
when you expect to have your schedule.**
Only ONE semester should be included below. This form may be copied for additional semester requests. Check only ONE of the following semesters:
SEMESTER YEAR: 20_____ SEMESTER YEAR: 20_____
_____ FALL _____ SPRING _____ SI
_____ FALL LATE START _____ SII
CHILD(REN) INFORMATION
NAME (Please Print) SEX AGE
DAYS AND TIMES DAYCARE IS NEEDED Please include actual hours needed.
Monday Tuesday Wednesday Thursday Friday Morning 8am – 12pm Afternoon 12pm – 5pm Evening 5pm – 10pm
_____ Approved for Childcare Assistance _____Not Approved _____ Childcare Center Registered _____________________________________________ Date _____________
FINANCIAL AID ELIGIBILITY VERIFICATION
_____________________________________ has met the financial need requirement as determined by the (Applicant name – Please print)
FAFSA for the following semester.
****Student does not have to be receiving financial aid to demonstrate financial need****
Please indicate only one semester:
___FALL 20_____
___FALL LATE START 20_____
___SPRING 20_____
___SPRING LATE START 20_____
___SI 20_____
___SII 20_____
Financial Aid Representative ______________________________ Date: _____-_____-_____ (signature)
______________________________ (printed name)
Student may copy this form for any additional semesters requested.
OR
_____ I am unable to file FAFSA, but I have submitted my income tax return and a completed copy of the EFC calculator at:
http://www.finaid.org/calculators/finaidestimate.phtml
