2019-2020 Extended Learning Center Reduced Rate Application
The reduced rate must be applied for each school year. Approval of the reduced rate is good only for the academic year for which application is made.
This application should only be filled out AFTER your application for enrollment to the program has been completed and you have applied and been denied for child care subsidy by the Watauga County Department of Social Services (DSS). For information on qualification see the Eligibility Standards document on the web page.
In addition to submission of this form please provide the following information to the Program Coordinator at your school or Program Director at the Central Office for all adults living within your household:
> your last W-2 form/s and tax statement showing line 37
> last paycheck stub/s
> student loan statement
> child support verification
> or any other documentation that supports verification of your income listed as gross income on your tax
> a copy of the DSS denial or waiting list letter showing your were denied or are currently on the waiting list.
Not providing requested documentation and information will result in a delay of approval. Subsidy does not start until the day of approval. The date of application is automatically recorded when it is submitted. You will be notified by e-mail of approval or denial.
To be eligible for the first day of the program August 20, 2018, this application must be submitted on or before August 10, 2018. All applications received after 4:30 p.m. on this date will be considered the for the following month provided spaces are still available. Must apply for a minimum of 4 days. Since reduced rate scholarships are extremely limited, priority will be given to applicants applying for the most days of care and the youngest children needing care. Middle School Volunteers are not eligible for the Reduced Rate Scholarship.
Privacy Act Statement
The confidentiality of the information on this application is protected by the "Right to Privacy Act (1974)". This information will only be used to determine your eligibility for reduced rates for the after school program.
Please Select School
Blowing Rock ELC
Cove Creek ELC
Green Valley ELC
Hardin Park ELC
Valle Crucis ELC
The reason I need child care is to help support me while I.....
Go to School
All Adults in my household work in the afternoons between the hours of 2:30 p.m. -6:00 p.m.
Are there special circumstances you would like us to consider?
(This could be situations like a child with special needs or that needs tutoring, an elderly care giver, or similar situations)
How many people are there in your household?
More than 5
Application must be made separately for each child to be considered for the reduced rate.
Please fill in the child's first and last name in the space below.
Please fill in the child's date of birth in the space below.
Priority will be given to the youngest children.
Please check the days of the week you are registering the children for
Minimum for receiving subsidy, 3 days per week (priority given to those registering for 5 days per week)
Gross (before taxes) household income per month.
Include all adults who live in your household.
Do the children receive a free or reduced price lunch?
I certify that the information I have given on this application is correct. I authorize the Watauga County Department of Social Services to share my subsidy application information with the Watauga County Schools for the purpose of confirming the information on this application. I also authorize the Child Nutrition office of the Watauga County Schools to disclose to the after school program whether or not the children listed on this application receive a free or reduced price lunch.
I agree to the statement above.
By typing my name below I agree by legal electronic signature to the terms of this application. (Please type name including slash marks as indicated below).
/ First Name, Last Name /
Please provide e-mail address by which you wish to be notified.
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Watauga County Schools.