Cape Cod Community College - CCAPMIS Grant Student Application Survey

General Information

CCAMPIS stands for Child Care Access Means Parents In School. It is a federally funded grant, which Cape Cod Community College (CCCC) received to assist student parents with their childcare cost while completing their degree.

Student parent applicants are considered for childcare assistance through CCAMPIS funding on the basis of eligibility status, financial income, need, resources and family contribution levels as per their FAFSA results.

If you have any questions about this application, please contact CCAMPIS Project Coordinator Laura Doane at ldoane@capecod.edu.

1.Please provide the following contact information.

First Name:

Last Name:

Mailing Address:

City/Town:

State:

Zip Code:

Phone Number (best number to contact you):

Alternate Phone Number (if applicable)

Email address:

2.Gender

Female

Male

Non-Binary

Prefer not to say

4.Ethnicity

Hispanic or Latino\Latina

Not Hispanic or Latino\Latina

6.Currently, what CCCC certificate or degree program are you enrolled in?

7.In what semester do you expect to graduate from CCCC?

Please indicate the semester (Fall, Spring, Summer) and the year.

Semester:

Year:

8.Are you using any of these services offered by CCCC? (check all that apply)

Academic Support Services (Tutoring, Math Lab, Writing Center)

Advantage/TRIO Program

Coaches & Mentors Program

O'Neill Center for Access and Support

SUCCESS program

Other support service (please specify)

Not using any CCCC support services

9.How many dependent children are in your household? Enter a number.

10.Please list the full name(s) and date(s) of birth of the child(ren) for whom you are seeking with childcare expenses.

Child # 1 Name:

Child # 1 Date of Birth (MM/DD/YYYY):

Child # 2 Name:

Child # 2 Date of Birth (MM/DD/YYYY):

Child # 3 Name:

Child # 3 Date of Birth (MM/DD/YYYY):

11.What child care facilities do you currently use? Please enter the name of each one is a separate box. If you are not currently using child care, please leave the question blank.

Childcare Facility #1:

Childcare Facility #2:

Childcare Facility #3

12.What childcare facilities would you like to use if granted CCAMPIS Support?

Childcare Facility #1:

Childcare Facility #2:

Childcare Facility #3

13.Do you currently receive financial assistance for your childcare expenses?

Yes

If yes, please list the source and amount.

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