CHILD CARE ASSISTANCE PROGRAM - APPLICATION FOR ASSISTANCE Please note, this form must be completed each semester that you request child care assistance. Name* First Last NSCC A#* Campus email*This must be your @my.nscc.edu email address Phone number*Semester for which you are requesting assistance* Enrollment status* Full time Part time How many children do you need assistance providing care for this semester?* 1 2 3+ For each child that you are requesting assistance with care, please provide the following:*Click the "+" button to add more childrenNameAgeDate of birth What is the name, address, and phone number of your child care provider(s)?*Is your child already enrolled with the provider listed above?* Yes No Please note, this program can only provide assistance with child care payments; we cannot help you find or secure a placement for your child.Terms and Conditions (by checking each box, you are indicating that you understand and accept the terms):* I affirm that I have completed the FAFSA for the current academic year. I affirm that I am the legal parent or guardian of the child(ren) for whom I am requesting assistance. I affirm that I am currently enrolled as a student at NSCC. I understand that my eligibility to participate in the Child Care Assistance Program is contingent upon my continued enrollment in at least 6 credit hours at Nashville State, with at least 50% of my classes meeting on campus (not online). If I drop below the 6 credit hour minimum, drop below the 50% on-campus course rate, or withdraw from classes entirely, I will be removed from the program. I understand that if I am removed from the program, I will stop receiving assistance on the date that I become ineligible (drop courses) and I will be responsible for any charges incurred after that date. I understand that I must successfully complete at least 75% of this semester’s coursework and otherwise comply with the terms of the program in order to remain eligible to request child care assistance next semester. I understand that the Child Care Assistance Program may not cover the full cost of my childcare. I understand that I am responsible for any child care fees that exceed the program’s maximum assistance amount each semester. I authorize NSCC Foundation staff to obtain information about my child(ren)’s attendance from my chosen provider. I agree to inform NSCC Foundation staff immediately if there are changes to my enrollment status or child care arrangements. CAPTCHANameThis field is for validation purposes and should be left unchanged.