EWC Emergency Childcare Assistance Application - Eastern Wyoming College - Eastern Wyoming College

Name(Required)

First

Last

Address(Required)

Street Address

Address Line 2

City

State

ZIP Code

Phone(Required)

Email(Required)

Enter Email

Confirm Email

Due to the costs of childcare, have you experienced any of the following financial hardships? (Please select any of the statements below that represent your current circumstances)(Required)

Underemployed due to childcare costs – (current position does not use one’s full capabilities so the individual attends college part-time or works several jobs to earn money for their living expenses and/or working in a relatively low-skilled, low-wage job beneath one’s skill level)

Unemployed – (unable to work and attend community college due to childcare costs)

Reduced college course load – (unable to enroll in additional college credits toward a degree or credential due to childcare costs)

Reduced credits earned in prior academic term – (required to drop credits from prior semester in current semester due to increased cost or loss of access to childcare)

Risk of reduced credits in the upcoming academic term due to inconsistent or reduced access or costs of childcare – (should funds not be available, credits would be dropped to accommodate childcare needs)

Childcare costs prohibitive – (current childcare costs create a financial burden impacting the ability to pay for housing, food, or other living expenses)

Other (please explain)

Explaination

Childcare Assistance Need—Do you need childcare assistance for the following?(Required)

Part-time childcare (Less than 20 hours per week throughout the academic term)

Full-time childcare (More than 20 hours per week throughout the academic term)

Number of children(Required)

Age of Children (For children under 4 years please use how many months old)(Required)

I agree to the following (Must attest to all the requirements below):

•The information contained in my application for an emergency grant related to financial hardships experienced by myself is true and accurate

• I agree to comply with all of my institution’s applicable policies, procedures and guidelines and agree to work toward completion of a recognized institutional credential.

• I affirm that the childcare provider I pay is licensed, exempt from licensing, or meets the requirements for Family, Friends, and Neighbors providing care.

• I affirm I do not receive childcare assistance from any other Department of Family Services (DFS) childcare assistance program.

Falsification under applicable law may result in Recipient’s liability under the False Claims Act, 31 U.S.C.{ 3729.et seq.

Student Signature(Required)

Date(Required)