Daycare Information and Agreement

This form provides ECC with important information about the daycare and student-parent/child(ren) who are being served through the childcare grant program.

Facility Name*
Facility director(s) or representative(s) who will complete monthly attendance verification and points of contact.*
Facility Phone Number*
Email Address*
Mailing Address*
Street Address Address Line 2 City ZIP / Postal Code
Physical Address
If different from mailing address

Street Address Address Line 2 City ZIP / Postal Code
Copy of NC State License or Religious Exemption Letter
Drop files here or

Accepted file types: pdf.
Completed W-9 Form
Drop files here or

Accepted file types: pdf.
Name of Student-Parent*
Name(s) of Child(ren)*
Current childcare rate for child(ren)*
Childcare rate billed*
- Weekly
- Monthly
Agreement
- I have read and understand all of the information provided on the homepage for the childcare program. I agree to the terms of the program and will complete all necessary paperwork by the 5th of each month by 12 p.m. in order to receive timely payment.
  
  I have completed all of the above information to the best of my knowledge and will provide updated information as needed, in a timely manner.
Name
This field is for validation purposes and should be left unchanged.

Edgecombe Community College

Childcare Financial Assistance Childcare Vendors

Daycare Information and Agreement

Daycare Information and Agreement