Technical College of the Lowcountry
New Horizon’s Childcare Assistance Program
2015-2016 PARTICIPANT INTAKE APPLICATION
Section I: General Information (Please Print)
Name ______Student # / SSN______
Address ______H Phone # ( ) ______- ______
______Daytime # ( ) ______- ______
Gender: Male FemaleDOB: _____/______/______
Ethnicity: Caucasian African-American Native American Hispanic Asian/Pacific Islander
Other ______
Marital Status: Single (never been married) Married Divorced Separated Widow(er)
# of dependents (list below): ______# in daycare: ______# in after-school care: _____
Child’s Name ______DOB _____/_____/_____ M F
Child’s Name ______DOB _____/_____/_____ M F
Child’s Name ______DOB _____/_____/_____ M F
Child’s Name ______DOB _____/_____/_____ M F
How did you hear about this program? ______
Section II: Educational Information
Highest Educational Level: Less than HS HS Diploma GED Some College Associate Degree
List all degrees, certificates, and/or diplomas received:
______
______
Current Student Status: Currently Enrolled New Transfer Readmit New Student
Major: ______Full-Time Part-Time Day Evening
Cumulative GPA: ______
Section III: Employment/Income Information
Employment Status:Full-Time Part-Time Seeking Employment Unemployed
If employed, provide information for current employer(s):
Company Name Job Title # of Years
______
______
If unemployed, provide requested information below:
Years as homemaker w/no substantial job outside home: _____
Years of paid part-time employment:_____ Years of paid full-time employment:______
Approximate gross family income: $1 - $5,000 $5,001 - $10,000 $10,001 - $15,000
$15,001 - $20,000 $20,001 - $25,000 $25,001+
Indicate approximate income amounts from the sources below, as applicable, per month.
Employment ______Vocational Rehabilitation ______AFDC ______
Child Support ______Veteran’s Benefits ______TANF ______
WIA Grant ______Unemployment ______ABC ______
Social Security ______Pell Grant (per semester) ______Food Stamps ______
Lottery ______Work Study ______
Other ______
How many miles (round trip) do you drive from your home to school each day? ______miles
Section IV: CareerGoals and Requested Services
Briefly describe your career goals (what you would like to be doing five years from now) and how completion of your current program at the Technical College of the Lowcountry assist you in achieving these goals: ______
______
______
______
Support Services Requested:
Child/Dependent Care Books Transportation Tutoring Career Counseling
Comments: ______
______
TheNew Horizons – Childcare program at the Technical College of the Lowcountry is funded through the Carl D. Perkins Career and Technical Education Act of 2006 (Perkins IV).
All of the information on this form is true and complete to the best of my knowledge. Any information which might be used for statistical purposes may contain my name, but will not be released to the general public.
I authorize theto consult with and release any pertinent data to support services, prospective employers, and/or training personnel on my behalf.
______
Applicant SignatureDate
Please return this form to: TCL – Financial Aid PO Box 1288, Beaufort, SC 29901 or 921 Ribaut Road, Building 2, Coleman Hall. Ph: 843-470-5961. Fax: 843-525-8285