Childcare Grant Application - Edgecombe Community College

First Name(Required)

Last Name(Required)

Student ID(Required)

Street Address(Required)

City(Required)

Zip Code(Required)

County of Residence(Required)

Student Email Address(Required)

Alternate Email Address

Home Phone(Required)

Cell Phone

Current Student Status(Required)

Full-time (12 or more credits per semester)
Half-time (6-11 credits per semester)
Less than half-time (less than 5 credits per semester)

Curriculum in which you are enrolled at ECC(Required)

Anticipated graduation date(Required)

Other Funding Sources

Department of Social Services Childcare Funding Application Status(Required)

I have applied for childcare funding assistance through my local Department of Social Services, and I am currently on the waiting list.
I have applied for childcare funding assistance through my local Department of Social Services, but I am not eligible for services.

DSS County(Required)

Reason for ineligibility of DSS Funding

Point of Contact at DSS for Verification(Required)

Phone for Contact at DSS for Verification(Required)

Down East Partnership for Children Childcare Funding Application Status

I am a resident of Nash or Edgecombe County and have applied for childcare funding through Down East Partnership for Children, and am on the waiting list.
I am a resident of Nash or Edgecombe County and have applied for childcare funding through Down East Partnership for Children, but am not eligible for services.

Name of DEPC Contact Person

Phone for DEPC Contact Person

Reason for ineligibility of DEPC funding

Children

Please only list those under the age of 5 and not currently enrolled in school.

Child 1 Name(Required)

Last Name, First Name

Child 1 Birthdate(Required)

Child 1 currently enrolled in childcare?(Required)

Yes
No

Child 2 Name

Last Name, First Name

Child 2 Birthdate

Child 2 currently enrolled in childcare?

Yes
No

Child 3 Name

Last Name, First Name

Child 3 Birthdate

Child 3 currently enrolled in childcare?

Yes
No

Explanation of Need(Required)

Provide a brief explanation of your need and why you should be considered for the Childcare Grant.

List additional child(ren), birthdate(s), and Y/N if they are currently enrolled in child care.

Last Name, First Name	Birthdate (mm/dd/yy)	Enrolled in child care? (Y/N)

Certification(Required)

I have read and fully understand the information in the Childcare Grant Application and certify that the above information is true.

I have contacted my local DSS or DEPC to verify any information I am unsure about.

I give permission for the Childcare Grant Manager at Edgecombe Community College to contact the individuals listed above to verify that the information I have provided is accurate, and understand that any incorrect information provided may result in a denial of my application for funding, or termination from the program.

I am aware that course attendance is mandated to remain eligible for funds and understand that verification of my class attendance will be required each month of the program.

I understand the eligibility requirements and responsibilities of the Childcare Assistance Program participant.

I understand that I will be responsible for childcare costs exceeding those paid by this grant. I hereby certify my willingness to participate in the program.

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