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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 INFORMATION UNIVERSITY 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

SECTION I – ISU STUDENT PARENT INFORMATION...Spouse/Partner SPOUSE/PARTNER’S FIRST NAME SPOUSE/PARTNER’S LAST NAME Spouse/Partner is also the biological parent of my child/ren

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Text of SECTION I – ISU STUDENT PARENT INFORMATION...Spouse/Partner SPOUSE/PARTNER’S FIRST NAME...

  • 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

    mailto:[email protected]

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  • 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

    Adults: Children: UID: First-Name: Last-Name: Date-Birth: Address: City: State: Zip: Phone: ISU-Email: Mil-Self: OffMil-NA: OffMil-SP: OffSP-School: Imm-Status: Home-Country: SP-First-Name: SP-Last-Name: SP-Bio-Parent: OffSP-Living: OffSP-Student: OffMajor: Minor: Grad-Sem-Yr: Hrs-Curr: Hrs-Cum: GPA-Recent: GPA-Cum: 1st-Sem: Off1st-College: OffTrans-Credits: Transf-College: Grant-Aid: Scholar-Aid: Student-Loans-Borrowed: Student-Loan-Aid: Child-Name: Child-DOB: Other: How-long-enrolled: How-Much: Units: Child-Name-2: Child-DOB-2: Provider-2: Child-Name-3: Child-DOB-3: Provider-3: Child-Name-4: Child-DOB-4: Provider-4: Student-Employer: Hours-Week: Student-Gross-Income: Assistant-Income: Student-Child-Supp: Student-SSI: Student-Unemployment: Student-Relatives: Student-Addtl: Student-Savings: SP-Employer: SP-Hours-Week: SP-Gross-Income: SP-Assistant-Income: SP-Child-Support: SP-SSI: SP-Unemployment: SP-Relatives: SP-Addtl: SP-Savings: SNAP: OffFIP: OffTANF: OffWW: OffMedicaid: OffHawk-i: OffCCA: OffCheck Box64: OffOther-Assistance: Sponsors: Sponsors2: Addtl-Assets: Resources-Country: Essay: Student-Schedule: OffStudent-Transcript: OffStudent-Aid-Award: OffStudent-Pay-Slips: OffStudent-Taxes: OffStudent-LOI: OffStudent-I20: OffSP-Schedule: OffSP-Transcript: OffSP-LOI: OffSP-I20: OffSP-Pay-Slips: OffSP-Taxes: OffText84: Text85: Text86: Text87: Text88: Text89: Text90: Text91: Text92: Text93: Text94: Text96: American-Indian: OffAsian: OffBlack: OffTwo-More: OffPacific-Islander: OffWhite: OffHispanic: OffSingle: OffMarried: OffLiving-Partner: OffSep-Divorced: OffCit-Yes: OffCit-No: OffFT: OffPT: OffFRESH: OffSOPH: OffJR: OffSR: OffTrans-No: OffTrans-Yes: OffFAFSA-No: OffFAFSA-Yes: OffPell-No: OffPell-Yes: OffDep: OffIndep: OffBA: OffAS: OffMS: OffPHD: OffPROF: OffNo-Degree: OffMasters: OffDoctorate: OffProfessional: OffCheck Box134: OffCheck Box135: OffCheck Box136: OffCheck Box137: OffCheck Box138: OffCheck Box139: OffCheck Box140: OffCheck Box141: OffCheck Box142: OffCheck Box143: OffCheck Box144: OffCheck Box145: OffCheck Box146: OffCheck Box147: OffCheck Box148: OffCheck Box149: OffCheck Box1: OffCheck Box2: Off