Child Care Grant Application

Applicant: Date:

Last Name: First Name: MI:

Mailing Address: City: State: Zip:

Home Phone: Cell or Alternate Phone:

Child Care:

Children requiring child care:

First Name: Last Name: DOB: Potty Trained: Yes No

Days and hours child care needed:

Applicant Signature:^* BearPass Number:

*A copy of a FSD and/or SCWIB benefit or denial letter must be attached. By signing, I agree to/acknowledge the following:

I must complete the 2017-2018 Free Application for Federal Student Aid. I authorize Missouri State University-West Plains to verify application information, and I specifically authorize Family Support Division, Ozark Action and Vocational Rehabilitation to release child care funding information to the University. The child care center may charge additional fees not covered by this grant, and those fees are my personal responsibility. The child care center has the right to cancel services if my child is not manageable or is excessively absent. Grants are awarded for one semester. I must reapply each semester. My academic progress will be reviewed at the conclusion of each semester. If my application is received after the deadline, it will be considered only if funding is available. Funding is limited and assistance may not be available to every applicant.

Office Notes:

Please provide completed form to the office of financial aid. Address: Missouri State University-West Plains, Office of Financial Aid, 128 Garfield Avenue, West Plains, MO 65775

Telephone: (417) 255-7243 FAX: (417) 255-7237

Please attach a copy of your current class schedule.

Funds awarded will not meet your total child care needs