List names and ages for children who will be in childcare:
Name Age
1. ________________________________________________ _____________
2. ________________________________________________ _____________
3. ________________________________________________ _____________
4. ________________________________________________ _____________
Childcare Provider Information
Name of Provider: ____________________________________________________________________
Street Address of Provider: _____________________________________________________________
City: _________________________________________ State: __________ Zip Code: _____________
Cost Per Week: $______________ Amount to be paid by student: $____________________
(Cost less amount paid by others)
I certify that the information I am submitting on this application is accurate to the best of my knowledge.
I understand this information may be verified. I understand that if I purposely give false information on
this application, it will be considered invalid and I will not be considered for any of the childcare funds.
____________________________________________________ ___________________
Student-Parent’s Signature Date
To be considered for Childcare funds you must:
Have at least a 2.00 GPA if you are a returning student
Be a resident of Rutherford or Polk county and be eligible for in-state tuition
Enroll in at least 6 credit hours per semester
File FAFSA to establish need
Not have received Childcare funds previously for a total of two years or more
ICC 405.doc 03/2015 Goldenrod
