Childcare Assistance for Professional and Technical Students

Application for Childcare Assistance

Professional & Technical Students
Student ID #*
When is your expected graduation from Panola College?:*

Spring 2025Summer 2025Fall 2025Spring 2026Summer 2026
Student Name*

First NameLast Name
Mobile Number*
Please enter a valid phone number.
Email where you can be reached*
example@example.com
Race/Ethnicity*
Gender*
I am (check all that apply) (For definitions see 20 U.S.C. 2302 and 29 U.S.C. 3102)*

an individual from an economically disadvantaged or low-income family (receiving assistance through SNAP, Social Security, and/or State or local income-based, public assistance)an individual with a disabilitya single parent or a single pregnant womanhomelessan English learnerout-of-workforce individual (an individual who is a displaced homemaker, as defined in section 3102 of title 29 ; or an individual who—has worked primarily without remuneration to care for a home and family, and for that reason has diminished marketable skills)currently in or have aged out of the foster care systema child of a member of the armed forces who is on active dutynone of the above
I am (check all that apply)

a single parent to a child under age 18a married parent to a child under age 18a separated parent to a child under age 18currently pregnantNone of the above
What is your major?*
ex: Business, Nursing, Welding
Semester for which you are applying for assistance*

Spring 2025
Where are your classes located? (choose all that apply)*

CarthageMarshallShelby College CenterShelby Regional Training CenterOnline
Source of total household income (check all that apply)*

Own salarySpouse's salaryParent's salaryAFDCSocial SecurityWIAChild supportFood stampsHousing subsidyStudent financial aid
I am a Professional & Technical student and requesting childcare assistance related to my academic needs:*

YesNo
I am an Academic student and requesting childcare assistance related to my academic needs:*

YesNo
What caused the need for childcare assistance? (Please provide a detailed/thorough response.)*
Dependent Child(ren) Information

Applications will be reviewed as they are received.

Make sure to check the email you used in this application for status, information, and/or further instruction.
Signature

Clear
Please verify that you are human*
Should be Empty:

	Child's Name	Date of BirthMM/DD/YY	Full-Time ChildcareYes/No	Part-Time ChildcareYes/No
1
2
3
4

Childcare Assistance for Panola College Students

If you are not enrolled in Spring 2025 AND have not completed the FAFSA for 2024-2025, your application will not be considered.

Eligibility Requirements for Childcare Assistance

Application for Childcare Assistance

Dependent Child(ren) Information

Applications will be reviewed as they are received.