Childcare Support Application Form

Program Application

Before completing the following Child Care Assistance Program Application, please log in to myGCC, select "Student Information System" (SIS), and verify that your address and contact information are correct. This will ensure faster processing.

STUDENT INFORMATION

* Student ID

* Pronouns (e.g., she/her)

* VCCS Student Email

* Personal or Alternate Email

* Preferred Phone Number

* May we contact you via text message?

* Military Affiliation

* Ethnic Background

HOUSEHOLD INFORMATION

* Are you the first in your family to attend college?

* Are you a single parent?

* Household Status

* Total number people in household (including yourself and your children)

* Are you the primary legal caretaker (full or joint custody) for your child or children?

* Do you have a child or children with special needs?

* Do you currently participate in The Child Care Subsidy Program through the Department of Social Services?

If yes, please provide a copy of your determination letter via e-mail to childcare@germanna.edu

* Are you in need of a Laptop Loaner to complete classwork?

Yes

No

* Please enter how many children you are seeking child care for by age category.

Infant (0-15 months)

Toddler (15 months-36 months)

Preschool (3-5 years of age)

School age (5-12 years of age)

CHILD CARE PROVIDER SELECTION

Through local and federal grant funds, Germanna Community College facilitates access to offsite child care providers. Germanna does not offer on-campus child care. Germanna Community College is not responsible for child care services rendered by providers or lack thereof, nor does Germanna endorse any providers. Parents are responsible for researching child care providers on their own prior to selecting. Vendors that are currently in partnership with Germanna are listed below. (Only licensed and accredited locations can be utilized.)

* Preferred child care provider

* None of the child care centers on the vendor list are in my area

Yes

No

PARTICIPANT AGREEMENT

Please indicate your agreement with the following statements:

I understand that the purpose of Germanna's Child Care Assistance program is to assist me with child care expenses so that I can succeed in completing coursework toward my degree or certificate.

I understand that the Child Care Assistance program may cover less than 100% of my child care expenses and I agree to pay the difference between my CCAMPIS award and the child care tuition costs.

I understand that I must complete a Free Application for Federal Student Aid (FAFSA) and share my Expected Family Contribution (EFC) and Financial Aid award with the Project Coordinator to complete the child care assistance program application process.

I understand that I must complete a Single Stop Screening to complete the child care assistance program application process.

I understand that I must continue to meet eligibility requirements and comply with program expectations to maintain support from the child care assistance program.

I agree to assume the cost of or make alternate child care arrangements if I am found to be ineligible for the child care assistance program at any time.

I authorize child care assistance personnel to access my records, including financial aid information, income level, current financial aid, and academic information. All information will remain confidential.

I understand that Germanna will report funding information, cumulative and term GPA, hours completed, and demographic information, with all personal identifying information removed to the U.S. Department of Education as required from federal grant recipients for an Annual Report.

I agree to complete a survey and participate in an interview and/or focus group related to the child care assistance program, if asked.

I understand that my information and feedback to surveys, interviews, and focus groups, compiled with those of other participants, may be included in annual evaluation reports required by child care assistance grant sources, and completed by Germanna’s external evaluator. I understand that my personal identifying information will not be shared in these reports.

SUPPORTING DOCUMENTS

Germanna requires the following supporting documents be submitted along with this application:

Child care Subsidy Determination Letter (if applicable)

Please send digital or scanned copies of these documents in PDF format via e-mail to childcare@germanna.edu. In the subject line, please include your Full Name and Germanna Student ID Number.

ELECTRONIC SIGNATURE

Typing your name below signifies that you are completing this form using an electronic signature. Submission of this digital application certifies that statements made on this application form are complete and true, to the best of your knowledge. You will be responsible for reporting changes to your financial status, child care status, and academic status to Child care Assistance Program team members immediately and to repay any award amount(s) you are no longer eligible to receive. You also agree to receive required disclosures or other communications related to this transaction electronically.

To continue with the electronic signature process, please enter your full name and click the ‘Submit’ button to save your information and submit your application and signature.

Your Signature

Sign above

If you prefer to opt out of the electronic signature, there may be delays in processing your application. Your application cannot be processed until you print, sign, date and submit your application to Germanna via e-mail at childcare@germanna.edu.

Child care funding assistance is contingent upon the program budget and grant funds received. Funding is limited and requests will be reviewed on a first-come, first-served basis. Please sign and submit your application as soon as possible.

If you need further assistance, please e-mail our Child Care Assistance Program team at childcare@germanna.edu.

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