Quarter ______Year ______
California State University, San Bernardino
CSUSB
Child Care Access Means Parents in School
Program
Child Care Funding Application:
The attached form is an application for child care subsidies through the CCAMPIS Program. In addition to the application, separate applications for admission to the Children’s Center or the Infant/Toddler Lab School must be completed.
IMPORTANT: Funding is not guaranteed. Awards are based upon the amount of space available at the child care centers and the number of applicants who apply and qualify for subsidies.
Application Instructions
· The CCAMPIS application must be turned in to the SAIL/CCAMPIS Office (UH-386) by ______at 4pm.
· All requested information must be completed and any documentation must be turned in at the time the application is submitted. Incomplete applications will not be processed.
· This application is valid for one academic year.
· Please read this entire packet before completing your application.
· Applications must be completed in ink or typed.
· If you should have any questions, please call Brittney Parish, CCAMPIS Project Coordinator, at (909) 537-7782.
California State University, San Bernardino
CCAMPIS Program Application
Child Care Access Means Parents in School
□ New Applicant □ Returning Applicant
Section A (To be completed by the applicant)
Full Legal Name: ______Date of Birth
My Coyote I.D.
Permanent Home Street Address: Apt #
City: State: Zip Code:
County of Residence:
Mailing address (if different from above address): Apt #
City: State: Zip Code:
CSUSB e-mail Address: @CSUSB.EDU Telephone #
Race/Ethnicity: (Select one or more)
q American Indian or Alaskan Native
q Asian
q Black or African American
q Hispanic or Latino
q Native Hawaiian or Other Pacific Islander
q White
q Decline to State
Citizenship (check one): qU.S. Citizen qPermanent Resident (see below) qNeither
1. U.S. permanent residents, holding the Alien Registration Receipt Card.
2. Permanent residents of the Trust Territory of the Pacific Islands or of the Northern Marina Islands.
If not a U.S. Citizen, what is your Alien Registration Number?
Revised: 1/23/2012
Quarter ______Year ______
Indicate your year in school: qFreshman qSophomore qJunior qSenior
Anticipated graduation date (mm/yyyy): ______
Your major: ______
Indicate the number of units you intend to register during the upcoming quarter: ______
Have you earned a baccalaureate degree? qYes qNo
**All of the following information should be completed based on your 201/2012 FAFSA Application.**
Number of persons living in household:
□ Female (dependent – live with parents/guardian)
□ Male (dependent – live with parents/guardian)
□ Female ( Single head of household)
□ Male (Single head of household)
□ Female (Married)
□ Male (Married)
□ Married Couple (both attend CSUSB)
□ Unmarried Couple (both attend CSUSB)
□ Unmarried Couple (one attends CSUSB)
Are you going to be receiving a Pell Grant for the 10/11 School year? qYes qNo
Complete the following for the children you wish to receive CCAMPIS funding for:
Revised: 1/23/2012
Quarter ______Year ______
Child’s Name Child’s Age Child’s Date of Birth
Application packet will not be accepted until all documentation is submitted
Please include copies of the following forms:
***Turn in separate application for Infant/Toddler Lab School and/or Children’s Center***
q Financial Aid Award Notification
q Enrollment Verification
Once eligible, I understand that in order to remain eligible for the childcare subsidy, I will be required to:
(Initial by each statement, Initialing indicates your understanding of the agreement to the following)
Provide evidence of having academic advising for each quarter for which I receive a subsidy by end of priority
registration.
Volunteer at the Children’s Center and/or the Infant/Toddler Lab School for a minimum of 10 hours per quarter.
Attend the mandatory parent orientation/workshop on the second Saturday of the new quarter from 9am-11am.
Participate in a quarterly survey designed to evaluate the CCAMPIS project.
Maintain at least half-time enrollment.
Provide a written report to the CCAMPIS coordinator of any changes in the information provided on this application
within 10 calendar days of the change. Failure to report such changes could result in a forfeit of grant funds.
Maintain satisfactory academic progress as defined by the CSUSB Financial Aid Office. This includes completing
the requisite number of units for the students enrollment status (half-time or full-time) and maintaining a 2.0 GPA.
I understand that if I do not fulfill ALL of my requirements, I will not receive CCAMPIS funds in the future.
I understand that I must complete a separate application for Infant/Toddler Lab School and/or Children’s Center.
23. Please read the following before signing your application:
I declare under perjury that the above information is true and correct to the best of my knowledge. I understand that the information about my eligibility may be reviewed by representatives of the State of California, the Federal Government, independent auditors, or others if necessary for the administration of the program. I understand that if the CCAMPIS staff denies this application for funding, I have the right to appeal. I understand that I must renew my eligibility each Fall. I understand that I must complete a separate application for Infant/Toddler Lab School and/or Children’s Center. I understand that this application is not complete until the application form has been signed and dated, and all documentation has been submitted by the applicant and verified by the CCAMPIS administration.
Applicant Signature: ______Date: ______
Revised: 1/23/2012