Childcare Assistance for Professional and Technical Students

Childcare Assistance for Panola College Students

PLEASE DO NOT SUBMIT THIS FORM MORE THAN ONCE PER SEMESTER. Completion of the form does not guarantee assistance.
Are you currently a student at Panola College?*

YesI plan to enroll next semester
You are not currently eligible to receive childcare assistance in Fall 2025. Please consider applying again in the future.
How did you hear about this program? (select all that apply)*

My instructorFriend or family memberFound on my ownSaw it on a sign/flyerPanola College employee (other than instructor/advisor)Another Panola studentAdvisorFound on Panola websiteRead about it in an emailOther
Are you a(n):*

I am an Academic Student (English, Drama, Music, Biology, Business Administration, Math, Pre-ADN, Pre-OTA, Pre-LVN, etc) requesting childcare assistance related to my academic needs.I am a Professional & Technical Student (Energy, Cosmetology, General Business, Cybersecurity, Nursing, EMT/Paramedic, etc.) requesting childcare assistance related to my academic needs.
I am (check all that apply)*

a single parent or a single pregnant womana married parent to a child under age 18a separated parent to a child under age 18currently pregnantan 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 disabilityhomelessan 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
Student ID #*
When is your expected graduation from Panola College?:*

Fall 2025Spring 2026Summer 2026Fall 2026Spring 2027
Student Name*

First NameLast Name
Mobile Number*
Please enter a valid phone number.
Email where you can be reached*
Double check your entry! You will not receive a response if email address is incorrect.
Race/Ethnicity*
Gender*
What is your major?*
ex: Business, Nursing, Welding
Semester for which you are applying for assistance*

Fall 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
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

You are not currently eligible to receive childcare assistance in Fall 2025. Please consider applying again in the future.

Dependent Child(ren) Information

Applications will be reviewed as they are received.