PVCC Child Care Access Means Parents in School Collaborative Program Application Form Academic Year Academic Year Select20222023202420252026Other… Enter other… Semester SelectFallSpringSummer Date Application CCAMPIS Agreement Please Indicate That You Have Read, Understand and Agree to the Following I understand that the goal of the CCAMPIS program is to assist me with child care expenses via child care vouchers so that I can succeed in completing credits towards my associate degree or certificate program at PVCC. My participation in the program is dependent upon my successful completion of semester credits on a consistent basis towards my degree or certificate. If I drop classes during any given semester, I agree to contact the PV CCAMPIS Program Director and understand that this may affect my enrollment in the PV CCAMPIS program. I understand that the CCAMPIS funds are to be used only when my child is in attendance at an approved regulated quality child care center or program. I understand that I will be asked to complete regular program evaluations and that this is essential to my ongoing funding through the CCAMPIS program. I will update my financial and academic status each and every semester that I am enrolled in the CCAMPIS program. I will participate in all other activities of the program including but not limited to parental education and student support services. I understand and give permission for the PV CCAMPIS Office to access my personal financial information through the Student Financial Aid Office to determine eligibility of enrollment in the CCAMPIS program. I understand that aggregate information, but no personal information will be shared with the United States Department of Education, the funder of this program. I have read and understand the guidelines of the PV CCAMPIS program and will abide by them. I understand that participation in this program/study is voluntary and that I may withdraw at any time with certain consequences such as possible loss in funding. 1. Applicant Information Name First Last E-mail Student MEID Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Application Status - Select -New (First time) CCAMPIS Applicant?Returning Applicant (Current Beneficiary)?Returning Applicant (Previous Beneficiary)? Contact Person (if we are unable to reach you) Contact Phone Relationship to you 2. Student Demographic Information Gender SelectMaleFemaleOther Marital Status - Select -SingleMarriedDivorcedNever MarriedSeparatedWidowedOther Race/Ethnicity American Indian or Alaska Native Asian American Hispanic or Latino Hawaii or other Pacific Islander Black or African-American White Are you connected to the military? Yes No If yes, are you - Select -Active MilitaryVeteranNational GuardReservesSpouse of MilitaryUsing Family Member’s GI Household Status SelectFemale (dependent-live with parents/guardian)Female (single NOT head of household)Female (single head of household)Female (Married)Male (Married)Male (dependent-live with parents/guardian)Male (single NOT head of household)Male (single head of household) Total household members (including yourself) How many dependent CHILDREN are in your household? Name, age, birth date of children (MM/DD/YYYY) 3. Academic Information What is your major/field of interest (FOI)? Year/Semester First Enrolled in PVCC? Academic Plan Associate Degree Certificate Transfer to university Other Academic Load Full Time Student Part Time Student Mode of Study - Select -In-personPart-time StudentHybridOther Time of Attendance - Select -DayEveningWeekendNon-traditional (Online) Total Number of Credits Completed as of date of application Expected Graduation Date Total number of credits required for graduation How many credits are you registered or expect to register for this semester How long have you been working toward your associate degree or certificate program What is your cumulative GPA? 4. Child Care Needs Indicate the different types child care arrangements you currently use Child care facility Care provider, Babysitters Friends Relatives Others Do you currently use a child care facility for your children? Yes No What is your average monthly cost for child care? Please list the daycare from our daycare partner list below that you are interested in taking your child. Daycare Partner List State the reason why you want to use this facility 5. Income Information Are you currently employed? SelectFull TimePart Time (work less than 30 hours per week)Not EmployedOther Are you currently receiving financial assistance for your child care expenses? Yes No Pell Grant Annual Award Amount Please note: Submission of CCAMPIS application DOES NOT guarantee entry into the program. If approved, student will be contacted by PV CCAMPIS Program Director to schedule an interview IMPORTANT: Only those with a lawful presence in the U.S. may qualify for MCCCD scholarships or federal financial aid. Any information you provide about your legal status when you apply for financial aid or scholarship may be subject to mandatory reporting to federal immigration authorities under AZ law. Students applying for MCCCD scholarships or federal financial aid must have ONE of the following documents on file in the Admissions office as evidence of lawful presence in the U.S. at time of submission. An Arizona driver license issued after 1996 or an Arizona non-operating identification license. A birth certificate or delayed birth certificate issued in any state, territory or possession of the United States. A United States certificate of birth abroad. A United States passport. A foreign passport with a United States visa. An I-94 form with a photograph. A United States citizenship and immigration services employment authorization document or refugee travel document. A United States certificate of naturalization. A United States certificate of citizenship. A tribal certificate of Indian blood. A tribal or bureau of Indian affairs affidavit of birth. Tribal members, the elderly and “persons with disabilities or incapacity of the mind or body,” may submit certain types of documentation under Section 1903 of the federal Social Security Act (42 United States Code §1396b, as amended by Section 6036 of the Federal Deficit Reduction Act of 2005) By submitting this application, I swear under penalty of perjury that the document(s) that I have submitted to demonstrate lawful presence in the United States are true.