CCAMPIS Grant Application

Section I: PERSONAL INFORMATION G#:________________________

1. Name: First:______________ Middle:_________ Last:___________________________
2. Address: ______________________City: _________________ State: ___ Zip:________
3. Phone: Day ( ) _____________ Evening ( ) _____________ Cell ( )_________________
4. MyPCC Email Address:_______________ Personal E-mail Address:_________________
5. Date of Birth:_____/______/______
6. Gender: 􀂈 Male 􀂈 Female
7. Household Status: Married Not Married and Dependent on Parents
Not Married and Independent
8. Child(ren) Name: ____________________ _________________ ___________________
9. Child(ren) Date of Birth: _____/_____/_______, _____/_____/_____, _____/_____/_____
10. Are you currently employed? Yes No
If yes, how many hours a week do you work?: _____ If yes, where?_______________
11. Are you military affiliated? Yes No
If yes, please explain relationship & military status: _________________________________
12. Race/Ethnicity: 􀂈 American Indian/Alaska Native 􀂈 Asian 􀂈 Black or African-American
􀂈 Hispanic or Latino 􀂈 Hawaiian or other Pacific Islander 􀂈 White 􀂈 Two or More Races
13. Pell Grant Status: 􀂈 Receiving Pell Grant 􀂈 Eligible, but not receiving Pell Grant

Section II: COLLEGE INFORMATION

17. Which campus do you attend most? 􀂈 Sylvania 􀂈 Cascade 􀂈 Rock Creek __ Southeast
18. Full-time enrollment status? 􀂈 Yes 􀂈 No How many credits? ________
19. What is your major? ____________ What is the highest degree completed?_____________
20. What is your current GPA? _____________ 21. Expected Graduation Date_____________
22. When is child care needed (check all that apply)?: 􀂈 Fall 􀂈 Winter 􀂈 Spring 􀂈 Summer

Section III: CHILD CARE PROVIDER/ASSISTANCE INFORMATION

23. Who takes care of your child(ren) currently? 􀂈 Self 􀂈 Family member 􀂈 Friend/neighbor
􀂈 Family Day Care provider 􀂈 Day Care Center 􀂈 Other___________________
24. Do you receive subsidized child care from another agency? 􀂈 Yes 􀂈 No
If no, have you applied for subsidized child care? 􀂈 Yes 􀂈 No
If yes, how long have you been on the waiting list? _____________

Revised 11/2023
 CCAMPIS Participation Agreement
By participating in the CCAMPIS program, students agree to the following:

1. Be Pell Grant Recipient or Pell Grant Eligible and be in good academic standing.
2. Provide proof of meeting with an academic advisor (signed GRAD Plan or other signed
documentation) at least once a term, to the CCAMPIS staff who will forward the information to the
Project Director. All students must provide a signed GRAD Plan to a CCAMPIS staff before
CCAMPIS funds are applied to the student account.

3. Discuss hardships that may interfere with the academic/financial aid plan with their CCAMPIS
staff who will direct the enrolled student to appropriate support services.

4. Complete an annual FAFSA and seek additional scholarship funds.

5. Participate in parent involvement opportunities in the CCAMPIS program.This may include but is
not limited to:
● Parent/teacher conferences
● Classroom volunteering
● Participating in field trips
● Parenting workshops
● Family events

6. Participants will pay a copay of $50 per month to the child care provider.

I agree to meet the terms of the participation agreement as listed above.

I understand that failure to do so may result in losing the child care grant.

___________________________________ _____________
Student Signature Date

TO BE COMPLETED BY CCAMPIS STAFF FOR OFFICIAL USE ONLY

Signed GRAD Plan in file Pell-recipient OR Pell-eligible

Confirmed Good Academic Standing

I certify that I have reviewed this application and verified that the applicant is Pell-eligible and meets all
CCAMPIS eligibility criterion. I declare that this applicant is eligible to receive the CCAMPIS funding.

Authorized Official: ________________________ Title: _____________________ Phone: ______________

Signature: ______________________________________________ Date: ____________________________

This student has completed an interview for entry into the CCAMPIS grant program either by
phone or in person on _____________ __________________________________
(Date) (CCAMPIS Staff Signature)

Revised 11/2023