Childcare Assistance Application

Personal Information

First Name

Email

Address

Last Name
Phone
City
State
Zip Code
Child Care Assistance Information

Childrens Names Needing Assistance

Child Name:
Date Of Birth:
Child Name:
Date Of Birth:
Child Name:
Date Of Birth:
Parents Information

First Name

Email

Address
Last Name
Phone
City
State
Zip Code
Church Affiliations:
Childcare Provider:
Enrolled:
Types of Assistance Needed:

Monthly Fee's:
First Time Receiving Assistance From Dorcas Ministries:

If No, Please Enter When:
Monthly Income Details

Place Of Employment:
Full Time, Part Time, Other:
Spouse's Employment:
Full Time, Part Time, Other:
Please List Assistance Not Considered Income (Medicare, Medicaid, Food Stamps, SSI, etc.)
Monthly Expenses

If You Have No Expense In A Category, put $0

Morgate Payments:
Rent Payments:
Food:
Electricity:
Gas:
Water:
Telephone:
Medical:
Clothing:
Childcare:
Cable:
Car Payment:
Travel Expenses (Tickets, Gas, etc):


Other Payments:

Loans:
Credit Cards:

Insurance:

Life:
Medical:
Car:

Total Expenses Per Month:
Questions

Why do you feel your child needs this kind of care/experience?

What circumstances in the family are currently effecting your financial situation?

Other Children Needing Assistance

Child Name:
Date Of Birth:
Child Name:
Date Of Birth:
Child Name:
Date Of Birth:
Type in todays date in this format with dashes: (YYYY-MM-DD)


Childcare Assistance Application


Dorcas Ministries
1231 N.E. Maynard Rd.
Cary, North Carolina 27513
(919)469-9861

I understand that the mission of Christian Community in Action is to support families and individuals in crisis. This emergency assistannce is not intended to be an income supplement or to be provided on a regular basis. By accepting the terms of this form, I give Dorcas Ministries permission to contact whomever necessary to verify my need, make a responsible decision regarding assistance to my household, and to seek further 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 provide will be used to verify my need, negotiate on my behalf, and to assist my household or other agencies assisting my household. My acceptance of this form indicated 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 my household and I will be barred from receiving any future assistance from Dorcas Ministries. Also, the incident may be shared with other organizations.

How To Apply


In order to successfully apply for assistance you must fill out the application on the left in its entirety. Once complete you may either

1)Submit the application online where it will be sent to Scholarship Committee for review

or

2)Click Create Word Document and print the application off either mail it or bring it to the Dorcas Ministries facility.