CHILD CARE ASSISTANCE PROGRAM - APPLICATION FOR ASSISTANCE Please note, this form must be completed each semester that you request child care assistance. The childcare facility must be licensed to receive assistance. Name* First Last NSCC A#* Campus email*This must be your @my.nscc.edu email address Phone number*Please select your main NSCC campus.*White Bridge RoadSoutheastClarksvilleDicksonWaverlyMadisonSemester for which you are requesting assistance* Enrollment status* Full time Part time Are you a Verteran student?* Yes No Are you a TN Promise student?* Yes No I don't know Are you a TN Reconnect student?* Yes No I don't know 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 Please provide the contact information for your childcare provider.*Click the "+" button to add more than one childcare provider.NameAddressCityStateZip CodePhone Number HiddenWhat 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.Do you currently participate in the Snap E&T Program?* Yes No and I am interested in signing up. No and I am NOT interested in signing up. The Supplemental Nutrition Assistance Program (SNAP) Employment and Training helps eligible participants achieve their vocational goals and increase self-sufficiency through funded education, skills training, and supportive services. SNAP E&T services are a combined effort between the Department of Human Services (TDHS), Department of Labor (TDLWD), and community partnerships.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.