The Adult Resource Center
Child Care Grant Application
Summer 202
0
The Child Care Grant provides custodial parents with child care funding assistance while the parent is attending
Lansing Community College. Child Care Grant funds are only payable to licensed child care providers.
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________
__________________________
__________________________
__________________________
_______________________
Name: Student Number:
Preferred Phone: Date of Birth:
MARITAL AND EMPLOYMENT INFORMATION
Marital Status:
Single
Separated
Married/Remarried
Divorced or Widowed
Employment status: Employed Unemployed
Do you have a rec
ent change in household size or marital status? Yes No
If ye
s, please briefly
explain the change and the approximate date of the change:
If Married/Remarried, what
is the reason yours spouse is unable to provide child care?
HOUSEHOLD INFORMATION
How many people are in your household? How many people in your (and your
spouses) household will be college students
dur
ing this school year?
Spouse (if you are married and living in the same home):
Children: Sex: Date of birth:
“Xif this
child needs
care:
Name:
M F
Name:
M F
Name:
M
F
Name:
M F
CH
ILD CARE PROVIDER INFORMATION
Name: Phone:
Address: City:
State: Zip:
Email: Providers Work Days and Hours:
Child Care License Number (two letters followed
by nine
numbers):
Is this an aftercare program/facility?
Yes No
Fee Charged:
$
H
ourly Daily
Weekly
_________________________________________ _______________________
FASFA INFORMATION
I have filed a 1920 FASFA:
Yes No
_______________ __________
_______________ ______________
I have completed all requests for verification from the Financial Aid Office:
Yes No
Have you received
any of the following between 2017-2018? Check all that apply:
Medicaid
SSI – Supplemental Assistance Income
SNAP Special Nutrition Assistance
Program Free or Reduced Lunc
h
TANF Temporary Assistance for Needy Famil
ies WIC
Housing/Public/Section
8 Subsidy Family/friends assistance
Income Spouse income
Othe
r Unt
axed Income Unemployment Compensation
Child S
upport Received Alimon
y Received
Will you be receiving GSRP, DHH
S Cash Assistance, or Head start funding? Yes
No - If Yes, provide documentation
INTERNATIONAL STUDE
NT INFORMATION
Are you an International Student? Yes No
If you checked Yes
you do not need to file a FAFSA. Pleas
e provide copies if your income, spouses income (if married),
parents income (if you are a dependent student), and any other forms of financial assistance you may receive.
Please sign below to verify that you agree to the conditions and responsibilities of this award and that you assume responsibility for
knowing La
nsing Community College policies.
1. If I drop a course, my grant will be decreased accordingly.
2. The check will be sent directly to the child care provider.
3. I will onl
y receive assistance for approved classes taken on a credit basis, not classes taken on an audit basis.
4. I underst
and my academic progress will be monitored, and funding decisions will be made by committee on a case by case basis.
5. I understand that the child care assistance funds are limited and may not be available in subsequent semesters.
6. I will rep
ort any changes in income, marital status, number of dependents, and/or change in child care to the ARC.
7. I give pe
rmission to the Adult Resource Center (ARC) at Lansing Community College to have access to my enrollment, Financial Aid,
skill level scores, academic progress, and
grade information.
8. I do here
by give permission to the staff of the ARC to release information pertaining to my child care grant, enrollment, and class
schedul
e to my licensed child care provider, and to the DHS.
9. Applications without documentation will not be able considered for the grant.
Lansing Co
mmunity College is an equal opportunity educational institution/employer. Lansing Community College programs and
activities a
re open for all
persons regardless of race, color, sex, age, religion, national origin, creed, ancestry, height, weight,
sexual orientation, gender identity, gender expression, disability, familial status, marital status, military status, veteran’s status, or
other
status as p
rotected by law, or genetic information.
SIGNATURES
I certify t
hat I am the custodial parent of the
children listed on
this application and can provide
proof of custody if requested by the Adult Resource
Center and/or th
e Financial Aid Office.
Applicant’s Initials:
Date:
I certify that all statements made on this application are true to
the best of my knowledge and I can provide proof of
information stated on this application if requested by the Adult
Resource Center and/or the Financial Aid Office.
Applicant’s Inititials:
Date:
Appli
cants
Signature: Date:
Drop off application to:
LANSING COMMUNITY COLLEGE
Gannon Building:
Starzone Center for Student Support
Mail application to:
ARC - 1130
Lansing Community College
P.O. Box 40010
Lansing, MI 48901-7210
For more information:
Call:
517-483-1199
Email:
AdultRC@star.lcc.edu
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