Office of Financial Aid
PO Box 804
Spindale, NC 28160
Application for Childcare Funds
2015 2016
The funds for this childcare program come from an appropriation from the North Carolina General
Assembly. The program is designed to assist student-parents attending community colleges throughout
North Carolina. This is a block fund which means each community college is allotted a certain portion of
the total appropriation. This is a limited fund and therefore not all applicants will receive assistance. If
you are selected to receive assistance, you will be contacted by Isothermal Community College.
Name: _________________________________ E-mail Address:____________________________
Student ID#: ____________________ Last 4 Digits of SSN: XXX XX - ___________________
Street Address: ___________________________________________________________________
City: ______________________________________ State: ________ Zip: ___________________
Phone Numbers: Home - ______________ Work - _______________ Cell - __________________
Program of study: _____________________ GPA: ___________
Marital Status: Single Married Widowed Divorced Separated
Total number of family members: ______
Are you currently employed: Yes No Est. 2015 Annual Income: $_________________
If married, is your spouse employed: Yes No Est. 2015 Annual Income: $________________
Have you applied for the Pell Grant: Yes Est. Date _____________ No
Please check all of the following forms of childcare assistance you are currently receiving:
DSS (Monthly Parent Fee $_______________)
WIA (Monthly amount $_______________)
Other ______________________________ (Monthly amount $_______________)
- Continued -
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