Scholarship--Information Review Form Survey

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* 1. Child's Full Name (please list the full name of the child you are applying for):

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* 2. Child's Date of Birth

Date / Time

Date

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* 3. Do you have other children (ages birth to 5) that you are applying for? If yes, please list their names and birthdates here:

Child #2 Full Name:

Child #2 DOB:

Child# 3 Full Name:

Child #3 DOB:

Child #4 Full Name:

Child #4 DOB:

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* 4. Physical Address:

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 5. Please enter your mailing address here if different from address above:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 6. Who does the child live with at the address above?

Both parents

Mother only

Father only

Parent & Step-Parent (married)

Parent & Step-Parent (unmarried domestic partner)

Legal Guardian(s)

Legal Custodian(s)

Foster Parent(s)

Other (please describe):

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* 7. Total Household Family Size (enter number of household family members):

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* 8. Please list ALL of the people who live at the child's / children's address. Start with the child/children you are applying for.

Person #1 Name:

DOB:

Relationship to Child:

Person #2 Name:

DOB:

Relationship to Child:

Person #3 Name:

DOB:

Relationship to Child:

Person #4 Name:

DOB:

Relationship to Child:

Person #5 Name:

DOB:

Relationship to Child:

Person #6 Name:

DOB:

Relationship to Child:

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* 9. If you did not have enough space to list all household members above, please list additional names, birthdates, and relationship to child applying for Scholarship here:

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* 10. What is your Preferred Contact Number?

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* 11. Would you like to add an alternate phone number?

Yes

If "yes", please list alternate telephone number here:

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* 12. At what email address would you like to be contacted?

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* 13. What is your preferred way for us to contact you?

Telephone

Either (no preference)

Any comments?:

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* 14. Parent/Step-Parent/Guardian #1 NAME (please type first & last name):

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* 15. Parent/Step-Parent/Guardian #1

Please check all that apply for Parent/Step-Parent/Guardian #1 (listed above):

Employed

Seeking Employment

In Post-Secondary Eduation (college)

In High School

Attending Job Training Program

Other (please specify):

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* 16. If you answered "Employed" to previous question (#15), please list place of employment (company/business name). Type N/A if unemployed.

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* 17. If Parent/Step-Parent/Guardian #1 is a student, please list the name of the high school or college in which he/she/they are attending. Type N/A if question does not apply to you.

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* 18. Is there another parent/step-parent/guardian living in the home?

Yes

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* 19. Parent/Step-Parent/Guardian #2 NAME (please type first & last name).
Type "N/A" if there is no other parent/step-parent/guardian is living in the household. Do NOT list the name of any parent/guardian that is not living in the household with the child.

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* 20. Parent/Step-Parent/Guardian #2

Please check all that apply for Parent/Step-Parent/Guardian #2 (listed above):

Employed

Seeking Employment

In Post-Secondary Education (college)

In High School

Attending Job Training Program

N/A (no parent/step-parent/guardian #2)

Other (please specify):

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* 21. If you answered "Employed" to previous question (#20), please list place of employment (company/business name). Type N/A if unemployed or if there is no parent/step-parent/guardian #2 in household.

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* 22. If Parent/Step-Parent/Guardian #2 is a student, please list the name of the high school or college in which he/she/they are attending. Type N/A if question does not apply to parent/step-parent/guardian #2 of if there is no parent/step-parent/guardian #2 in household.

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* 23. Does anyone living in the household currently receive child support payments?

Yes

If yes, please list monthly amount and who receives:

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* 24. Does anyone living in the household currently receive Social Security payments?

Yes

If yes, please list monthly amount and who receives:

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* 25. Does anyone living in the household currently receive Unemployment compensation?

Yes

If yes, please list weekly amount and who receives:

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* 26. Are there any other types of income received by anyone living in the household? Please note: WIC, food stamps, housing assistance, and Work First payments are not sources of countable income and do not need to be reported.

Yes

Other (please specify):

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* 27. What is the name of the child care facility you have chosen for your child to attend if approved for the SSDC Child Care Scholarship Program? *Please note that you must select a 4 or 5 star child care facility in Davidson County.

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* 28. By typing your initials in the box below, you acknowledge the following:

Parent/guardian understands that it is their responsibility to choose a child care center from the approved list of centers that work with the Smart Start of Davidson County (SSDC) Child Care Scholarship Program.

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* 29. By typing your initials in the box below, you acknowledge the following:

Parent/guardian understands that once they have chosen a child care center, it is their responsibility to work out a start date with the center's director.

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* 30. By typing your initials in the box below, you acknowledge the following:

Parent/guardian understands that it is their responsibility to inform SSDC Child Care Scholarship staff of their center choice and projected start date before coming on the program.

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* 31. By typing your initials in the box below, you acknowledge the following:

Parent/guardian understands that the SSDC Child Care Scholarship Program will not start payment to their chosen child care center until the start date listed on the SSDC Child Care Scholarship Program contract created by SSDC staff member(s).

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* 32. By typing your initials in the box below, you acknowledge the following:

Parent/guardian understands that if their child/children start attending a child care facility before the parent/guardian has signed their SSDC Child Are Scholarship Program contract, parent/guardian is responsible for paying the cost of care out-of-pocket for any days child/children attend before their SSDC Child Care Scholarship contract start date.

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* 33. BY TYPING YOUR NAME BELOW, PARENT/GUARDIAN(S) AGREE(S) THAT ALL OF THE INFORMATION REPORTED ON THIS FORM IS TRUE AND CORRECT AND THAT ALL INCOME IS REPORTED. PARENT/GUARDIAN UNDERSTANDS THAT THIS INFORMATION IS BEING GIVEN FOR THE RECEIPT OF STATE FUNDS; AND THAT CHILD CARE SCHOLARSHIP PROGRAM OFFICIALS MAY VERIFY THE INFORMATION ON THIS FORM.
*Parent/guardian, please type your first & last name below:

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* 34. Completion Date

Today's Date:

Date

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* 35. Supporting Documentation-Check Stubs

Please attach most recent 8 weeks of check stubs for any parent/guardian living in the home (8 most recent if paid weekly, 4 most recent if paid bi-weekly/semi-monthly, 2 most recent if paid monthly)