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Child care financial assistance application

Child Care Subsidy for University of Utah Student Parents

In order to be considered for any child care financial assistance, all information must be provided.
New applications are due each semester.

Program Information

Semester applying for

Are you currently enrolled in a child care program?

YesNo

Name of Child Care Program

Other Child Care Program

Have you received an acceptance letter from the child care program for the semester you are applying for the subsidy?

YesNo

Have you attended a Financial Assistance for Child Care Orientation?

Yes
No

Parent 1 Information (must be a student)

First Name

Last Name

Address 1

Address 2

City

State/Province

Zip/Postal Code

Phone

uNID

(e.g. u0123456)

Year in School

Major

Credit Hours this Semester

Potential Graduation Information

Potential Semester

Potential Year

GPA

Have you completed a FAFSA form?

YesNo

Are you receiving a Pell Grant?

YesNo

Gender

MaleFemalePrefer not to disclose

Ethnicity

American Indian or Alaskan NativeAsianBlack or African-AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOtherPrefer not to disclose

Please indicate other ethnicity

Citizenship

US CitizenPermanent ResidentNon-US Citizen on a temporary Visa

Military Status

Place of Employment

Work Phone

Household Status

MarriedNot married and dependent on parentsNot married and independent

Do any other adults live in the household?

YesNo

Add Parent 2 info (if applicable)

Parent 2 Information

Parent 2 First Name

Parent 2 Last Name

Parent 2 Address

Same as Parent 1Different Address

Parent 2 - Address 1

Parent 2 - Address 2

Parent 2 - City

Parent 2 - State/Province

Parent 2 - Zip/Postal Code

Parent 2 - Phone

Parent 2 Email

Is Parent 2 a student?

YesNo

Parent 2 uNID (if University of Utah student)

(e.g. u0123456 or enter N/A if not U of U student)

Parent 2 - Year in School

Parent 2 - Major

Parent 2 - Credit Hours this Semester

Parent 2 Potential Graduation Information

Potential Semester

Potential Year

Parent 2 - GPA

Parent 2 - Gender

MaleFemalePrefer not to disclose

Parent 2 -Ethnicity

American Indian or Alaskan NativeAsianBlack or African-AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOtherPrefer not to disclose

Please indicate other ethnicity for Parent 2

Parent 2 - Citizenship

US CitizenPermanent ResidentNon-US Citizen on a temporary Visa

Parent 2 - Military Status

Parent 2 - Place of Employment

Parent 2 - Work Phone

Parent 2 - Household Status

MarriedNot married and dependent on parentsNot married and independent

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

1st child

2nd child

3rd child

4th child

5th child

6th child

7th child

8th child

Child Information

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

Child First Name

Child Last Name

Child Nickname

Child Date of Birth

Child Age

Child Gender

MaleFemalePrefer not to disclose

Child Ethnicity

American Indian or Alaskan NativeAsianBlack or African-AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOtherPrefer not to disclose

Child lives with

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 ANNUAL Income Amount for each item listed below for Parent 1 (P1) and Parent/Guardian 2 (P2).

P1 - Money, wages or salary

P2 - Money, wages or salary

P1 - Net income from self-employment

P2 - Net income from self-employment

P1 - Social Security Income

P2 - Social Security Income

P1 - Dividends, interest income

P2 - Dividends, interest income

P1 - Public assistance/welfare

food stamps (Horizon Card)

P2 - Public assistance/welfare

food stamps (Horizon Card)

P1 - DWS child care assistance, etc.

P2 - DWS child care assistance, etc.

P1 - Pension and annuities

P2 - Pension and annuities

P1 - Unemployment

P2 - Unemployment

P1 - Disability Insurance

P2 - Disability Insurance

P1 - Worker’s Compensation

P2 - Worker’s Compensation

P1 - Alimony received

P2 - Alimony received

P1 - Child support received

P2 - Child support received

P1 - Veteran’s pensions

P2 - Veteran’s pensions

P1 & P2 Other Income Description

P1 - Other Income Amount

P2 - Other Income Amount

Academic Financial Assistance

Report total GROSS ANNUAL Income Amount for each item listed below for Parent 1 (P1) and Parent/Guardian 2 (P2).

P1 - Grants (Pell, SEOG, and others)

P2 - Grants (Pell, SEOG, and others)

P1 - Scholarships

P2 - Scholarships

P1 - Stipends

P2 - Stipends

P1 - Tuition reduction

P2 - Tuition reduction

P1 - Tuition reimbursement

P2 - Tuition reimbursement

P1 - Student Loans **

P2 - Student Loans

**Note: Student loan data is for information only. It will not be counted in total income resources.

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.

YesNo

I have answered the questions truthfully with regard to income resources and student status to the best of my knowledge.

YesNo

I understand that I must provide adequate verification to support any of the claims made on this application.

YesNo

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.

YesNo

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.

YesNo

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.

YesNo

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.

YesNo

I understand that by submitting this application electronically, I agree to the same terms that apply to a signed application.

YesNo

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