CCAMPIS Grant Application

Child Care Subsidy for University of Utah Student Parents

Child must be enrolled in a nationally accredited program to apply.
In order to be considered for enrollment in the CCAMPIS Program, all information must be provided.
New applications are due each semester.

Program Information
Indicates a required field.

Semester applying for
Are you currently enrolled in a child care program? Yes No
Name of Child Care Program
If other, please list program name.
Have you received an acceptance letter from the child care program for the semester you are applying for the subsidy? Yes No
Have you attended a Financial Assistance for Child Care Orientation? Yes No

Parent 1 (Student) Information

First Name
Last Name
Address 1
Address 2
City
State/Province
Zip/Postal Code
Phone(e.g. xxx-xxx-xxxx)
Email
Email Confirmation
uNID(e.g. u0123456)
Year in School
Major
Credit Hours this Semester
Potential Graduation Date
GPA
Have you completed a FAFSA form? Yes No
Are you receiving a Pell Grant? Yes No
Gender Male Female
Ethnicity American Indian or Alaskan Native Asian Black or African-American Hispanic or Latino Native Hawaiian or Pacific Islander White Other Prefer not to disclose
Please indicate other ethnicity.
Citizenship US Citizen Permanent Resident Non-US Citizen on a temporary Visa

If permanent resident holding the Alien Registration Receipt Card, list Alien Registration number

If permanent resident, I am a permanent resident of of the Trust Territory of the Pacific Islands or of the Northern Marina Islands

Provide Visa #

Provide I-20 #

Visa expiration date

Military Status
Place of Employment
Work Phone(e.g. xxx-xxx-xxxx)
Household Status
Do any other adults live in the household? Yes No
If yes, please state relationship.

Parent 2 Information

First Name
Last Name
Parent 2 Address Same as above Different

Address 1

Address 2

City

State/Province

Zip/Postal Code

Phone
(i.e. xxx-xxx-xxxx)
Email
Email Confirmation
Is Parent 2 a student? Yes No

uNID (if University of Utah student)(e.g. u0123456 or enter N/A if Not U of U Student)

Year in School

Major

Credit Hours this Semester

Potential Graduation Date

GPA

Gender Male Female
Ethnicity American Indian or Alaskan Native Asian Black or African-American Hispanic or Latino Native Hawaiian or Pacific Islander White Other Prefer not to disclose
Please indicate other ethnicity.
Citizenship US Citizen Permanent Resident Non-US Citizen on a temporary Visa

If permanent resident holding the Alien Registration Receipt Card, list Alien Registration number

If permanent resident, I am a permanent resident of of the Trust Territory of the Pacific Islands or of the Northern Marina Islands

Provide Visa #

Provide I-20 #

Visa expiration date

Military Status
Place of Employment
Work Phone(e.g. xxx-xxx-xxxx)
Household Status

Child's/Children's Information

Please, only provide information for the child(ren) that will be enrolled in child care this semester.

First Child

First Name
Last Name
Nickname
Date of Birth: MonthDayYear
Age
Gender
Ethnicity American Indian or Alaskan Native Asian Black or African-American Hispanic or Latino Native Hawaiian or Pacific Islander White Other Prefer not to say
Please indicate other ethnicity.
Child lives with Both Mother Father Shared Other
If other, specify who the child lives with.

Second Child

First Name
Last Name
Nickname
Date of BirthDayYear
Age
Gender
Ethnic Origin American Indian or Alaskan Native Asian Black or African-American Hispanic or Latino Native Hawaiian or Pacific Islander White Other Prefer not to say
Please indicate other ethnicity.
Child lives with Both Mother Father Shared Other
If other, specify who the child lives with.

Third Child

First Name
Last Name
Nickname
Date of BirthDayYear
Age
Gender
Ethnic Origin American Indian or Alaskan Native Asian Black or African-American Hispanic or Latino Native Hawaiian or Pacific Islander White Other Prefer not to say
Please indicate other ethnicity.
Child lives with Both Mother Father Shared Other
If other, specify who the child lives with.

Income Resources

All applicants, please fill out this section as this information is required to determine eligibility and subsidy award.

Report total GROSS income for each item listed below.

Income Resources

U of U Student Parent

Parent 2/Guardian 2

Annual Amount $

Money, wages or salary

Net income from self-employment

Social Security income

Dividends, interest income

Public assistance/welfare and/or food stamps (Horizon card)

DWS child care assistance, etc.

Pension and annuities

Unemployment

Disability Insurance

Worker’s Compensation

Alimony received

Child support received

Veteran’s pensions

Other

Academic Financial Assistance	U of U Student Parent	Parent 2/Guardian 2
	Annual Amount $	Annual Amount $
Grants (Pell, SEOG, and others)	U of U Student Parent - Grants (Pell, SEOG, and others) - annual amount	Parent 2/Guardian 2 - Grants (Pell, SEOG, and others) - annual amount
Scholarships	U of U Student Parent - Scholarships (Pell, SEOG, and others) - annual amount	Parent 2/Guardian 2 - Scholarships (Pell, SEOG, and others) - annual amount
Stipends	U of U Student Parent - Stipends - annual amount	Parent 2/Guardian 2 - Stipends - annual amount
Tuition reduction	U of U Student Parent - Tuition reduction - annual amount	Parent 2/Guardian 2 - Tuition reduction - annual amount
Tuition reimbursement	U of U Student Parent - Tuition reimbursement - annual amount	Parent 2/Guardian 2 - Tuition reimbursement - annual amount
Student loans - for information only, will not be counted in total income resources	U of U Student Parent - Withdrawn student_loans - annual amount	Parent 2/Guardian 2 - Withdrawn student_loans - annual amount

Academic Financial Assistance

U of U Student Parent

Parent 2/Guardian 2

Annual Amount $

Grants (Pell, SEOG, and others)

Scholarships

Stipends

Tuition reduction

Tuition reimbursement

Student loans - for information only, will not be counted in total income resources

Family Information for Household

Family Size
Total number of
children in the home
Include children under the age of 18 and living at home.
Children's Ages
1. 1st child
2. 2nd child
3. 3rd child
4. 4th child
5. 5th child
6. 6th child
7. 7th child
8. 8th child

Additional Documentation

Additional documentation is required to complete the CCAMPIS Grant Application.

Please explain your financial circumstances in detail so that we may better understand your need.
A class schedule for each parent who is a student at the university.
A Screen shot of the 'Financial Aid Status' from CIS for each parent who is a student at the university.
Two current check stubs or letter from employer stating earnings (for each parent/step-parent/guardian in the home)
Copy of your current tax return (first two pages of form 1040/1040A, not the attachments)
Current documentation for all other sources of income (unemployment, child support, alimony, public assistance/welfare, food stamps, child care assistance from DWS or other sources, etc.)
Current SAR (Student Aid Report from www.fafsa.ed.gov) for parent/step-parent/guardian living in the household

Submit documentation via email to Center for Child Care and Family Resources

Confirmation

I am a current student at the University of Utah and I am enrolled in classes this semester. I have answered the questions truthfully with regard to income resources and student status to the best of my knowledge. I understand that I must provide adequate verification to support any of the claims made on this application. I understand that it is my responsibility to notify the University of Utah Center for Child Care & Family Resources of any changes in the information I provided in this application. I understand that if awarded, the Center for Child Care & Family Resources will be contacting my provider regarding my child's schedule and rates to implement CCAMPIS funding. I understand that it takes time to process this application and it is my responsibility to pay my child care tuition on time regardless of when the CCAMPIS Child Care subsidy gets to my child care provider. I understand that if I am awarded a subsidy, I will be required to attend a workshop and complete a survey designed to evaluate the CCAMPIS project. I understand that by submitting this application electronically, I agree to the same terms that apply to a signed application.
Name

Main Navigation

PLEASE NOTE: THIS SITE WILL BE UNDERGOING ROUTINE MAINTENANCE ON MONDAY, JULY 27, 2020 AND WILL BE UNAVAILABLE FROM 10 PM-11 PM. WE APOLOGIZE FOR THE INCONVENIENCE.

(Child Care Access Means Parents in School)

Child Care Subsidy for University of Utah Student Parents