Child Care Financial Assistance

We know that by empowering families, our entire community benefits.

We can help you find high-quality child care and resources for paying for it.

We serve families in Aberdeen, Fayetteville, Laurinburg, Lumberton, Raeford, Rockingham, Southern Pines, Troy, Wadesboro, and the surrounding areas (Anson, Cumberland, Hoke, Montgomery, Moore, Richmond, Robeson, and Scotland counties).

Child Care Resource Assistance Interest Form

Page 1

Information collected on this form, including personal information, will be used to help inform our team on how best to serve you and your family and for statistical data purposes. Personal data is subject to our Privacy Policy.

HOUSEHOLD INFORMATION

Parent/Guardian's First Name

Parent/Guardian's Last Name

Parent's Phone Number

Parent's Email Address

 Total number of children (including infants) and adult dependents in your household

Is your family currently displaced (homeless)?

Yes

No

ADDRESS INFORMATION

If your family is displaced (homeless), list your current location below, even if it is temporary and you do not receive mail there.

Street Address

City

State

Zip Code

Page 2

CHILD/DEPENDENT INFORMATION

This section of the form can be used to record information about one or multiple children/dependents.  Enter details below about a child/dependent and, if needed, use the "Add another response" link in the lower right part of this page to add information about another child/dependent.  Repeat as needed. 

Child/Dependent's First Name

Child/Dependent's Last Name

Your relationship to Child/Dependent

Birth ParentLegal Guardian

Child/Dependent's gender

FemaleMalePrefer Not to Answer

Child/Dependent's date of birth

Does your Child/Dependent have a diagnosed disability or special need?

YesNoCurrently in Testing

Is your Child/Dependent currently attending a childcare or adult daycare program?

YesNo

Name of program your Child/Dependent is currently attending

Have you chosen a childcare or adult daycare program for your Child/Dependent?

YesNo

What is the name of the childcare or adult daycare program you have chosen?

Does your Child/Dependent require wrap-around care?

YesNo

Page 3

INFORMATION ABOUT YOU

EMPLOYMENT

Employment Status

Full TimePart TimeUnemployed

Number of hours you work each week

Name of your employer

MILITARY

Are you currently active duty military?

NoYes, ArmyYes, NavyYes, Air ForceYes, Marines

Are you currently deployed?

YesNo

What is your Pay Grade?

SCHOOL

Are you a student?

YesNo

How often do you attend school?

Full TimePart Time

Page 4

INFORMATION ABOUT MARITAL STATUS

Marital Status

SingleMarriedDivorcedWidowed

Spouse First Name

Spouse Last Name

What is your Spouse's employment status?

Full TimePart TimeUnemployed

Number of hours Spouse works each week

Name of Spouse's employer

Is your Spouse currently active duty military?

NoYes, ArmyYes, NavyYes, Air ForceYes, Marines

Is your Spouse currently deployed?

YesNo

What is your Spouse's Pay Grade?

Is your Spouse currently a student?

YesNo

How often do they attend school?

Full TimePart Time

Thank you for taking the time to complete this form.  When all required fields are complete, please click the Submit button below to send your responses to the Partnership for Families and Children of Cumberland County.

The North Carolina Partnership for Children and the Smart Start Initiative help fund this work.

Help us in our efforts to ensure all children receive a sound education, beginning at birth, and families receive the support they need to ensure success.