CCAMPIS Grant Application

1. Semester applying for Select Semester Fall 2021 Spring 2022 Summer 2022
2. Are you currently enrolled in a child care program?

   Yes No
3. Name of Child Care Program Select Program UKids – Presidents Circle Program BioKids ECEC UKids – Guardsman Way St. John’s KinderCare – West Jordan Other (please list below)
4. If other, please list program name.
5. Have you received an acceptance letter from the child care program for the semester you are applying for the subsidy?

   Yes No
6. Have you attended a Financial Assistance for Child Care Orientation?

   Yes No

1. First Name
2. Last Name
3. Address 1
4. Address 2
5. City
6. State/Province Select State/Province: Utah Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ----------------- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Islands Quebec Saskatchewan Yukon Territories ----------------- --- Not Applicable ---
7. Zip/Postal Code
8. Phone(e.g. xxx-xxx-xxxx)
9. Email
10. Email Confirmation
11. uNID(e.g. u0123456)
12. Year in School Select Year Freshman Sophomore Junior Senior 5th Year Senior Graduate Student PhD 2nd Bachelors
13. Major
14. Credit Hours this Semester
15. Potential Graduation Date Select Graduation Date Summer 2020 Fall 2020 Spring 2021 Summer 2021 or later
16. GPA Select GPA 4.0 3.75 3.5 3.25 3.0 2.75 2.5 2.25 2.0 1.75 1.5 Below
17. Have you completed a FAFSA form?

    Yes No
18. Are you receiving a Pell Grant?

    Yes No
19. Gender

    Male Female
20. 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
21. Please indicate other ethnicity.
22. 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
23. Military Status Military Status Active duty in the U.S. Armed Forces Veteran of the U.S. Armed Forces National Guard U.S. Armed Forces Reserves Not applicable
24. Place of Employment
25. Work Phone(e.g. xxx-xxx-xxxx)
26. Household Status Select Status Married Not married and dependent on parents Not married and independent
27. Do any other adults live in the household?

    Yes No
28. If yes, please state relationship.

1. First Name
2. Last Name
3. Parent 2 Address

   Same as above Different
Address 1
Address 2
City
State/Province Select State/Province: Utah Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ----------------- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Islands Quebec Saskatchewan Yukon Territories ----------------- --- Not Applicable ---
Zip/Postal Code
4. Phone
   (i.e. xxx-xxx-xxxx)
5. Email
6. Email Confirmation
7. 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 Select Year Freshman Sophomore Junior Senior 5th Year Senior Graduate Student PhD 2nd Bachelors
Major
Credit Hours this Semester
Potential Graduation Date Select Graduation Date Fall 2015 Spring 2016 Summer 2016 Fall 2016 Spring 2017 Summer 2017 or later
GPA Select GPA 4.0 3.75 3.5 3.25 3.0 2.75 2.5 2.25 2.0 1.75 1.5 Below
8. Gender

   Male Female
9. 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
10. Please indicate other ethnicity.
11. 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
12. Military Status Military Status Active duty in the U.S. Armed Forces Veteran of the U.S. Armed Forces National Guard U.S. Armed Forces Reserves Not applicable
13. Place of Employment
14. Work Phone(e.g. xxx-xxx-xxxx)
15. Household Status Select Status Married Not married and dependent on parents Not married and independent

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

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.

1. Income Resources	U of U Student Parent	Parent 2/Guardian 2
   	Annual Amount $	Annual Amount $
   Money, wages or salary	U of U Student Parent - Money, wages or salary - annual amount	Parent 2/Guardian 2 - Money, wages or salary - annual amount
   Net income from self-employment	U of U Student Parent - Net income from self-employment - annual amount	Parent 2/Guardian 2 - Net income from self-employment - annual amount
   Social Security income	U of U Student Parent - Social Security income - annual amount	Parent 2/Guardian 2 - Social Security income - annual amount
   Dividends, interest income	U of U Student Parent - Dividends, interest income - annual amount	Parent 2/Guardian 2 - Dividends, interest income - annual amount
   Public assistance/welfare and/or food stamps (Horizon card)	U of U Student Parent - Public assistance/welfare and/or food stamps - annual amount	Parent 2/Guardian 2 - Public assistance/welfare and/or food stamps - annual amount
   DWS child care assistance, etc.	U of U Student Parent - DWS child care assistance - annual amount	Parent 2/Guardian 2 - DWS child care assistance - annual amount
   Pension and annuities	U of U Student Parent - Pension and annuities - annual amount	Parent 2/Guardian 2 - Pension and annuities - annual amount
   Unemployment	U of U Student Parent - Unemployment - annual amount	Parent 2/Guardian 2 - Unemployment - annual amount
   Disability Insurance	U of U Student Parent - Disability Insurance - annual amount	Parent 2/Guardian 2 - Disability Insurance - annual amount
   Worker’s Compensation	U of U Student Parent - Worker’s Compensation - annual amount	Parent 2/Guardian 2 - Worker’s Compensation - annual amount
   Alimony received	U of U Student Parent - Alimony received - annual amount	Parent 2/Guardian 2 - Alimony received - annual amount
   Child support received	U of U Student Parent - Child Support received - annual amount	Parent 2/Guardian 2 - Child Support received - annual amount
   Veteran’s pensions	U of U Student Parent - Veteran’s pensions - annual amount	Parent 2/Guardian 2 - Veteran’s pensions - annual amount
   Other	U of U Student Parent - Other - annual amount	Parent 2/Guardian 2 - Other - annual amount

   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

1. Family Size Select Family Size 2 3 4 5 6 7 8 9 10
2. Total number of
   children in the home
   Include children under the age of 18 and living at home. Number of Children 1 2 3 4 5 6 7 8
3. 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 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