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I understand that the mission of the Dorcas Ministries educational assistance programs is to provide financial aid to eligible applicants. This assistance is not intended to be an income supplement or to be provided on a regular basis. By accepting these terms and conditions, I give Dorcas Ministries permission to contact whomever necessary to verify my need, to make a responsible decision regarding my request for assistance, and to contact additional resources with regard to my request. This permission includes but is not limited to, landlords, mortgage companies, utility or other service providers, medical providers and pharmacies.
I also understand the information I have submitted will be used to verify my need, to negotiate on my behalf, and to provide the requested assistance. By submitting this application, I hereby acknowledge acceptance of these terms and conditions and declare that all information I have given Dorcas Ministries is accurate and complete to the best of my knowledge.
I understand that if I have given false information in this submission, my household and I will be barred from receiving future assistance of any type from Dorcas Ministries. Also, I understand that the incident may be shared with other organizations.
Full Time Part Time
Annual income: $
Single Parent Household: Yes No
Family Members Living in Home
School you are attending or planning to attend:
Number of years you plan to attend:
Are you receiving financial aid? (scholarship, loans, grants, other)
Yes No Type of Aid: $
Goal of this education experience:
o Tuition $
o Books $
o Supplies $
o Exam Cost: $
o Travel Expenses $
Miles Traveled for school each week:
o Childcare Monthly Fee: $
Name of Child:
Childcare Contact Name:
Name of Childcare Facility:
Childcare Contact Phone:
Childcare Contact Email:
Reference (Non-Family Member)
Gross Annual Household Income
· Salary including tips
· Unemployment compensation
· Social Security compensation
· Child Support
· Aid for Dependent Children
Other Assets or Sources of Income
Yes No $
Medicaid for Children or Household
Medicare for Children or Household
North Carolina State Voucher for Childcare
Total Monthly Expenses
What dollar amount are you able to pay? $ Yearly? Monthly?
Have you ever received Assistance from Dorcas Ministries? Yes No
If yes, what kind?
If yes, when?
Please share why you are applying for financial assistance?
I certify that all information is true and complete to the best of my knowledge. I grant permission to Dorcas to verify this information. I agree to notify Dorcas if my financial status should change or if my child is no longer participating at the designated place for which I am receiving assistance.
(Signature will be required at time of interview) Date of Signature
To submit the application,
click Yes to accept the
otherwise the application
will not be submitted.
I accept the Terms and Conditions:
Submit this form on-line.
FOR OFFICE USE ONLY:
Date of interview: Date Processed: Date Notified:
Assistance Awarded: Payable to: