First Name *

Last Name *

Former or Maiden Name

Phone Number *
Enter the best phone number to reach you, area code first. Dashes/formatting will be added automatically.

Student ID Number *
Enter your Student ID Number. You can find your student ID number here: https://nr.my.vccs.edu/jsp/userconfig.jsp

Program of Study *
Your Program of Study (curriculum) at NRCC:
Please choose a Program of Study... AA&S Business Administration AA&S Education AA&S Engineering AA&S Engineering Computer Sci AA&S General Studies AA&S General Studies Comp Sci AA&S General Studies Fine Art AA&S General Studies Visual Co AA&S Liberal Arts AA&S Science AAS 3D Solid Modeling Speciali AAS Accounting AAS Administrative Suppt Tech AAS Amer Sgn Lang Engl Interpr AAS Arch & Engineering Design AAS Business Management AAS CADD Game Tech and Anim Sp AAS Early Childhood Develop Sp AAS Electrical Engr Tech AAS Electronics Tech AAS Engineering Design Tech AAS Fashion Merch & Retailing AAS Fiber Optics Specializatin AAS Forensic Science AAS Grap Design Comm Spec AAS Help Desk Support Speciali AAS Human Services AAS IT Comp Graph Web Dsgn Sp AAS IT Cyber Security AAS IT Game Design Spec AAS IT Mobile & Web Applic Dev AAS IT Network and Tech Suppor AAS Information Technology AAS Instr & Control Automation AAS Instrum/Comput Aid Drf Spe AAS Machine Technology AAS Marketing AAS Marketing Management Spec AAS Med Adm Support Specializa AAS Networking Specialization AAS Networking Technology Spec AAS Nursing AAS Paralegal Studies AAS Paralgl Admin Support Spec AAS Police Science AAS Small Business Manag Speci Administrative Support Tec Architecture Automotive Banking and Finance Business Administration CSC Child Dv Infant & Toddler CSC Acc Rec/Pay CSC Accounting/Keyboarding CSC Accounting/Keyboarding CSC Accounts Receiv/Payable CSC Administrative Assistant CSC Administrative Assistant CSC Advanced Manufacturing CSC Advanced Welder CSC Air Con & Rf CSC Alternative Energy CSC American Sign Lang. CSC American Sign Language CSC Autocad CSC Automotive Drivability CSC Basic Machine Tool Oper CSC Basic Tool & Die Making CSC Child Development CSC Child Development CSC Computer Numerical Control CSC Construction Technology CSC Cost Accounting Clerk CSC Cost Acct Clerk CSC Cyber Security CSC Diesel Powered Vehicles CSC Digital Design CSC Educational Interpreting CSC Educational Interpreting CSC Electrical-Construction CSC Electricity CSC Electricity CSC Emergency Medical Tech Int CSC Engineering Design Tech CSC Entry-Level Welder CSC Fiscal Practices CSC Fiscal Practices CSC Game Des, Web Des & Animat CSC Game Design, Web & Anima CSC Health Information Mgmt CSC Human Resource Practices CSC Human Resources CSC Instrument Mechnics CSC Interpreting for the Deaf CSC Interpreting for the Deaf CSC Laboratory Technician CSC Laboratory Technician Adv CSC Law Enforcement CSC Law Enforcement CSC Machine Operations CSC Mechatronics CSC Medical Coding CSC Medical Office Assistant CSC Medical Office Assistant CSC Nurse Aide CSC Org Leadership & Dev CSC Organi Leadersip & Dev CSC Paralegal Assistant CSC Paralegal Assisting CSC Payroll Clerk CSC Payroll Clerk CSC Pharmacy Technician CSC Prd Inv Mgn CSC Production & Inventory Mgm CSC Refrigeration & Air Cond CSC Renewable Energy Basics CSC Retail/Sales Assisting CSC Small Bus Mgmt CSC Small Business Management CSC Supervision & Leadership CSC Supervision & Leadership CSC Visual Comm Design CSC Work Relations CSC: IT Game Design & Anim CSC: IT Mobile Applications CSC: Info Tech Foundations CSC: Information Tech Network CSC: Operator Career Studies Cert, Accounting Cert. Early Child Development Cert. General Education Cert. Human Service Cert. Industrial Maintenance Cert. Practical Nursing Cert. Welding Technology Cert. Word Processing Child Care Child Care Specialization Clerk Stenographer Community Social Services Computer Applications Spec Computer Information Syst Computer Machine Operation Construction Data Processing Diploma Auto Analysis Repair Diploma Machine Operations Drafting & Design Technolo Education Electrical Maintenance Emergency Medical Services Fire Science General Education General Studies Interpreter For The Deaf Liberal Arts Office Systems Assisting Office Systems Technology Science Science Secretarial Science Special History Curriculum Word Processing Specializa

Marital Status*
Married
Single
Other

If other, please explain

Are you a single parent?*
For the purpose of the CAPS program, we are defining this as: You, the student, are the only adult in the household and the only adult available to provide income and care for the children. Do you feel like you meet this definition?”
Yes
No

Number of Dependents *

Ages of Dependents *

Monthly Income *

Do you pay for childcare services (either traditional daycare center or in-home daycare)?*
Yes
No

Monthly Childcare Expenses *

Do you receive a childcare subsidy from the Virginia Department of Social Services?*
Yes
No

How many credits are you currently enrolled in at NRCC? *

Do you receive any of the following?
Medicaid or Supplemental Security Income (SSI)
Supplemental Nutrition Assistance Program (SNAP)
Free or Reduced Price Lunch
Temporary Assistance for Needy Families (TANF)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Childcare subsidy from the Virginia Department of Social Services
Other...
Please enter other financial benefits you receive:

Please describe any obstacles or barriers you face as a student parent as you work towards your educational goals? *

Do you think you would benefit from participation in the CAPS program, and why? *

What kinds of things do you wish you had better access to? What resources / services / training would be most helpful? *

Selection Criteria & Benefits

If selected, I agree to the following terms and conditions:*

1. I am a single parent. The CAPS program defines this as: The student is the only adult in the household and the only adult available to provide income and care for the children.
2. I understand my participation is contingent on my enrollment and financial aid eligibility at NRCC.
3. I understand that my academic progress will be evaluated each semester to continue in this program.
4. I understand that I will be offered the opportunity to participate in CAPS activities (including cohort meetings, individual coach and counselor/advisor meetings, and career readiness activities) and am expected to be an active participant.
5. I understand that as a CAPS Fellow, I may be eligible for a stipend of up to $2,000.

Yes
No

Email Address*
Please enter your email address so we can contact you. We will send you a copy of your answers.

Submit