Fall 2026 Childcare Assistance Application
Completion of the form does not guarantee assistance.
Are you currently a student at Panola College?
*
Yes
No
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Fall 2026 Childcare Assistance Application
Completion of the form does not guarantee assistance.
You currently do not meet the eligibility requirements to receive childcare assistance. You may apply in the future. Please exit the application.
When is your expected graduation from Panola College?:
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Fall 2026
Spring 2027
Summer 2027
Fall 2027
Spring 2028
Student ID #
*
Student Name
*
First Name
Last Name
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email where you can be reached
*
example@example.com
Race/Ethnicity
*
Please Select
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Middle Eastern or North African
White (non-Hispanic)
Asian
Native Hawaiian or Pacific Islander
Other
Gender
*
Please Select
Male
Female
What is your major?
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ex: Business, Nursing, Welding
Semester for which you are applying for assistance
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Fall 2026
Where are your classes located? (choose all that apply)
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Carthage
Marshall
Shelby College Center
Shelby Regional Training Center
Online
Source of total household income (check all that apply)
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Own salary
Spouse's salary
Parent's salary
AFDC
WIOA
Social Security
Child support
Food stamps
Housing subsidy
Student financial aid
How did you hear about this program? (select all that apply)
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My instructor
Friend or family member
Found on my own
Saw it on a sign/flyer
Panola College employee (other than instructor/advisor)
Another Panola student
Advisor
Found on Panola website
Read about it in an email
Other
Are your children currently attending a licensed daycare?
Please Select
Yes
No
I'm not sure if the provider is licensed
How many children will need childcare?
Please Select
1
2
3
4
5
6
Do your children attend childcare full-time or part-time?
Please Select
Full-Time
Part-Time
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Fall 2026 Childcare Assistance Application
Completion of the form does not guarantee assistance.
I am a(n):
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Academic Student (English, Drama, Music, Biology, Business Administration, Math, Pre-ADN, Pre-OTA, Pre-LVN, etc)
Professional & Technical Students (Energy, Cosmetology, General Business, Cybersecurity, Nursing, EMT/Paramedic, etc.)
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Fall 2026 Childcare Assistance Application
Completion of the form does not guarantee assistance.
I am TSI complete in (to be verified):
Math
English
Both (Math & English)
Unsure
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Next
Fall 2026 Childcare Assistance Application
Completion of the form does not guarantee assistance.
You currently do not meet the eligibility requirements to receive childcare assistance. You may apply in the future. Please exit the application.
Back
Next
Fall 2026 Childcare Assistance Application
Completion of the form does not guarantee assistance.
Have you completed a FAFSA application for 2026/2027?
*
Yes
No
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Fall 2026 Childcare Assistance Application
Completion of the form does not guarantee assistance.
Are you a single parent to a child under age 18?
*
Yes
No
Are you a married parent to a child under age 18?
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Yes
No
Are you a legally separated parent to a child under age 18?
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Yes
No
Are you currently pregnant?
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Yes
No
Are you 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?
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Yes
No
Are you an individual with a disability?
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Yes
No
Are you homeless?
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Yes
No
Are you an English learner?
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Yes
No
Are you an out-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)?
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Yes
No
Are you currently in or have aged out of the foster care system?
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Yes
No
Are you a child of a member of the armed forces who is on active duty?
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Yes
No
You currently do not meet the eligibility requirements to receive childcare assistance. You may apply in the future. Please exit the application.
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Fall 2026 Childcare Assistance Application
Completion of the form does not guarantee assistance.
I am a Professional & Technical student and requesting childcare assistance related to my academic needs:
*
Yes
No
I am an Academic student and requesting childcare assistance related to my academic needs:
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Yes
No
What caused the need for childcare assistance? (Please provide a detailed/thorough response.)
*
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
Please verify that you are human
*
Submit
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