OFFICE USE ONLY
DATE RECEIVED:
RECEIVED BY:
ATTACHMENTS Student Spouse Student Spouse PELL GRANT STATUS Schedule Transcript SFA award
Tax return Pay slips LOI
R – Receiving E – Eligible/Not Receiving
LIG – Low Income Grad Student LIF – Low Income Foreign Student
Complete and return the application to: Family Resource Center, 2623 Bruner Drive, Suite 1010, Ames, IA, 50010
OR scan and send electronically to [email protected] (515) 294-8827 or (515) 294-3149
SECTION I – ISU STUDENT PARENT INFORMATIONUNIVERSITY ID# FIRST NAME LAST NAME GENDER DATE OF BIRTH
Female Male
US POSTAL ADDRESS CITY STATE ZIP CODE
PHONE ISU EMAIL
RACE/ETHNICITY (check one) American Indian or Alaskan Native Hawaiian or Other Pacific Islander
Asian White
Black or African American Hispanic or Latino
Two or more races
MARITAL STATUS HOUSEHOLD SIZE Single Living with Partner
Married Separated/Divorced
# Children MEMBER OF THE MILITARY Self N/A
Spouse/Partner
SPOUSE/PARTNER’S FIRST NAME SPOUSE/PARTNER’S LAST NAME Spouse/Partner is also the biological parent of my child/ren Spouse/Partner lives with me Spouse/Partner is a student at:
ARE YOU A CITIZEN OR PERMANENT RESIDENT OF THE U.S.?
Yes No – please provide: Immigration status: Home country:
SECTION II – ISU ACADEMIC INFORMATION
STUDENT STATUS CLASSIFICATION
Full-Time Part-Time Freshman Sophomore Junior Senior Master’s PhD Professional
MAJOR MINOR EXPECTED GRADUATION SEMESTER & YEAR
NUMBER CREDIT HOURS GRADE POINT AVERAGE (GPA) This is my first semester Current Semester Cumulative Most Recent Semester Cumulative
I am the first person in my immediate family to attend college
Have you previously attended any other college/university?
No Yes IF YES, number of credits earned: Name of college/university:
Have you completed a FAFSA? Do you receive a Pell Grant? According to FAFSA, you are considered a:
No Yes No Yes Dependent Student Independent Student
Approximately how much in federal and/or private student loans have you borrowed so far? $
For the current academic year, indicate the amount you receive for each type of financial aid:
Grants $ Scholarships $ Student Loans $
What is the highest degree you have obtained thus far?
Associate’s Bachelor’s Master’s PhD Professional I have not obtained a college degree
#Adults
2 | Updated September 2019
SECTION III – CHILD CARE INFORMATIONCHILD’S NAME (whom you wish to receive CCAMPIS) CHILD’S GENDER CHILD’S DATE OF BIRTH
Male Female
CURRENT CHILD CARE PROVIDER ISU Child Care Center at Veterinary Medicine University Community Childcare ISU Child Development Laboratory School
Other (please specify)
How long has your child been enrolled in the above child care program? How much do you pay for child care, per month?
Have you applied to the Department of Human Services to receive Child Care Assistance? No Yes
Have you been approved for Child Care Assistance? No Yes IF YES, how many units per week?
If funding is available, multiple children enrolled in campus child care services may be eligible for CCAMPIS funding. Please provide names and birthdates of any additional children living with you in your home. CHILD NAME DATE OF BIRTH CURRENT CHILD CARE PROVIDER
CHILD NAME DATE OF BIRTH CURRENT CHILD CARE PROVIDER
CHILD NAME DATE OF BIRTH CURRENT CHILD CARE PROVIDER
SECTION IV – HOUSEHOLD INCOME If you are not married but living with the other parent of the child receiving services, you must also provide their financial information, including tax documents.
INCOME RESOURCES STUDENT PARENT SPOUSE/PARTNER Are you currently employed? No Yes No Yes
Name of Employer:
Average number of hours worked per week:
Annual GROSS income from work: $ per year $ per year
Income from graduate assistantship: $ per month $ per month
Child Support: $ per month $ per month
Supplemental Security Income (SSI): $ per month $ per month
Unemployment: $ per month $ per month
Amount expected from relatives, parents, or friends: $ per month $ per month
Additional income not listed above: $ per month $ per month
Balance in savings account(s): $ $
Current services you receive: SNAP/Food Assistance FIP/Family Investment Program TANF/Temporary Assistance for Needy Families Welfare to Work Medicaid Hawk-i DHS Child Care Assistance Other:
SECTION V – INTERNATIONAL STUDENT STATUS ONLY International students must complete this section (you must submit a copy of your Form I-20, including your spouse’s Form I-20, if applicable)
Does your spouse/partner’s immigration status allow them to work in the U.S.? No Yes
Amount expected from sponsors: $ per month OR $ per year Please disclose any additional money, assets, and or property your family may have in another country, including a dollar value:
In which country are these resources held? ______________________________________________
3 | Updated September 2019
SECTION VI – ESSAY Please provide any information you would like our office to consider when reviewing your application (e.g., financial need, the impact that the CCAMPIS Grant Program would have on your education, and/or other extenuating circumstances). Feel free to use additional paper if needed.
4 | Updated September 2019
REQUIRED DOCUMENTATION The following documents must be submitted with the CCAMPIS application. Incomplete applications will not be considered until all required documentation has been received by Child Care & Family Services.
All Students:
Current class schedule
Unofficial transcript which includes most recent completed semester
Current Student Financial Aid award letter for the current academic year
Pay slips for the most recent three months (if employed)
Tax return/Form 1040 for the most recent tax year (please black out all social security numbers)
Graduate Students ONLY:
Letter of Intent (if you have a graduate assistantship)
International Students ONLY:
Form I-20
If you are married and/or living with the biological parent of your child, you must also submit the following documentation:
If your spouse/child’s biological parent is a student:
Current class schedule
Unofficial transcript which includes most recent completed semester
Letter of Intent (if s/he has a graduate assistantship)
Form I-20 (international students only)
If s/he is employed:
Pay slips for the most recent three months
Tax return/Form 1040 for the most recent tax year (if filed separately)
If any of the above required documentation is NOT included with the CCAMPIS application, please provide explanation for each missing document (i.e., you did not file taxes last year because you were not employed).
5 | Updated September 2019
LETTER OF AGREEMENT
In order to receive the CCAMPIS grant assistance for child care services, ALL CCAMPIS recipients must participate in the University Family Resource Program designed to build knowledge and relationships. The program provides resources, workshops and discussion groups and may include topics such as parent child communication, early childhood education curriculum, discipline/guidance, developmental stages of childhood, managing family, work, and school, and other family activities.
Married individuals, where the non-applicant is neither employed nor attending college, is considered to be available for child care, and will not be eligible to participate in the program.
Please initial that you have read, understand, and agree to the following:
______ The goal of the CCAMPIS program is to assist me with child care expenses so that I can remain enrolled at ISU, and persist towards earning my degree.
______ My participation in CCAMPIS is dependent upon my successful completion of semester credits on a consistent basis towards earning my degree.
______ If I drop classes during any given semester and fall below full-time status, I will notify the CCAMPIS Program Director immediately, and understand I will no longer be eligible for CCAMPIS.
______ If my spouse/partner is no longer employed and/or enrolled as a student, I will notify the CCAMPIS Program Director immediately, and understand I will no longer be eligible for CCAMPIS.
______ I will be immediately responsible for 100% of all child care fees charged by the center if I withdraw as a student from ISU.
______ My child/ren must regularly attend child care and frequent unexplained absences may result in dismissal from CCAMPIS.
______ I will complete regular program evaluations as requested by Child Care & Family Services, which is essential to my ongoing funding through CCAMPIS.
______ I will attend Child Care & Family Services programs each semester that I am enrolled in CCAMPIS.
______ I must meet with the CCAMPIS Program Director or Program Assistant every semester
______ I understand and give permission for Child Care & Family Services to access my financial and academic information through the Student Financial Aid Office to aid in determination of eligibility for CCAMPIS.
______ I understand that aggregate information will be shared with the U.S. Department of Education in Washington D.C., which funds this program.
I have read and understand the attached guidelines and hereby certify that the information in this application is complete and accurate to the best of my knowledge. I understand and accept the obligations of the program and will provide a written report to the Program Director of any changes in the information provided on this application within 10 days of the change. If I do not, I understand that I am financially responsible for all child care tuition costs charged by the child care center. Changes may include, but are not limited to, my ISU enrollment, credit hours, and ISU financial status.
I also give the office of ISU Child Care & Family Services permission to disclose any information to the campus child care centers for the purposes of managing this grant.
Signature of Student Date