PERKINS CHILD CARE ASSISTANCE APPLICATION

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1 Check ALL that apply: PERKINS CHILD CARE ASSISTANCE APPLICATION SEMESTER YEAR: 20_ SEMESTER YEAR: 20_ Fall Spring SI SII Fall Late Start Spring Late Start Spring Mini Please PRINT: Name: Address: ID # : Phone: Program of Study (Major) _ Emergency Contact: Address: Relationship: Phone: Child Care Center Name Address: Phone # Contact Person 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

2 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) be single parent OR 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): be enrolled in or declare intent to enroll in a vocational-technical program. 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 have dependent child(ren) 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 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. ***INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED***

3 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

4 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. Morning 8am 12pm Monday Tuesday Wednesday Thursday Friday Afternoon 12pm 5pm Evening 5pm 10pm Approved for Childcare Assistance Not Approved Childcare Center Registered Galveston College representative signature and stamp Date

5 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: Revised 06/12/jw

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