Scholarship App

CHILD CARE SCHOLARSHIP APPLICATION

Lovin Touch Learning Center Child Care Scholarship Program

No current childcare scholarships

My child's child care scholarships will expire within 45 days

Type of Provider Used for Care:

Informal Relative Care: Informal Non-Relative In Child's Home Care

Section 2 Applicant Information Name (Last, First, Middle):

Name (Last, First, Middle)

Female Male

Social Security Number (SSN) (optional)

Date of Birth (DOB): MM/DD/YYYY

Single/Never Married Divorced Widowed

Race

Are yo[Thispanic/Latino? No Yes

Primary Language Spoken in Home

Alien Status (if not a citizen): See choices below

Do you have Active Military Status? YesNo

Yes

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White

Permanent Resident Asylee Alien Granted Conditional Entry Parolee (1 yr. or more) Alien Whose Deportation is Withheld

Refugee Battered Alien Spouse, Child or Parent of Child Undocumented Child of Lawfully Admitted Alien

Street

City

State

Mailing Address, if different:

Email Address

example@example.com

Do you pay Child Support to children outside of the home?

Are you a minor parent (under 18)?

Do you receive SNAP (food stamps)?

Do you receive a Housing Subsidy?

Section 3 Need for Care Information

1. Do you receive Temporary Cash Assistance (TCA)?

No

If yes, Start Date

Date

2. Is TCA for the children in your care only?

3. How many people are in your household? 4. What is your annual gross income?

Number

Job Search/Worl Community Service Public School (Elementary, Middle or High School) College (Undergraduate)

6. Do you have assets of one million dollars?

No

7. Which of the below describes your family's current living or housing situation?

a) Do you lack a fixed, regular, and adequate nighttime residence?

b)Are you sharing the housing of other persons due to loss of housing. reason (sometimes referred to as doubled-up)?

c) Are you living in motels, hotels, trailer parks, or camping grounds due to lack of alternative adequate accommodations?

d) Are you living in emergency or transitional shelters?

e) Are you caring for a child abandoned in hospitals or awaiting foster care placement?

f)Is your primary nighttime residence that is a public or private place not designed for, or ordinarily used as. a regular sleeping accommodation for human beings?

9)Are you living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings?

h) Are you and your children migratory?

8 Are you responsible for any children with a disability?

Yes

No

9.Do you want Child Care Assistance for a child that is not your child by birth or marriage, but is related to you and lives in your home?

10. How many children that are not yours by birth or marriage, are you caringiter (relative) ) See the above question 11. Are you or anyone in your household receiving Supplemental Security Income (SSI)?

Number

Name (Last, First, Middle)

Date of Birth (DOB)

Date

SSN (optional)

Race

Are you Hispanic/Latino? YesNo

Alien Status (if not a citizen): See choices below

American Indian or Alaskan Native

Asian Black or African American Native Hawaiian or Pacific Islander White

Permanent Resident Asylee Alien Granted Conditional Entry Parolee (1 yr. or more) Alien Whose Deportation is Withheld

Refugee Battered Alien Spouse, Child, or Parent of Child Undocumented

Child of Lawfully Admitted Alien

1. Is this child receiving Supplemental Security Income (SSI)?

2. What is the child's relationship to you? 1 3. Does this child have a disability?

4. Does this child receive benefits from Social Security?

5. Have you applied for child support for this child? 6. Do you receive child support for this child?

NoIf no, please see instructions on page 6.

7. What is the name of this child's absent parent(s)?

8. Is this child in Head Start?

NoIf yes, what is the start date?

9. If using Informal Relative Care, what is the relationship of the provider to the child?

Name (Last, First, Middle)

Date of Birth (DOB)

Date

SSN (optional)

Are you Hispanic/Latino? YesNo

Allien Status (if not a citizen): See choices above

1. Is this child receiving Supplemental Security Income (SSI)?

2. What is the child's relationship to you? 3. Does this child have a disability?

4. Does this child receive benefits from Social Security?

5. Have you applied for child support for this child?

NoIf no, please see instructions on page 6.

6. Do you receive child support for this child? 2 7. What is the name of this child's absent parent(s)?

8. Is this child in Head Start?

NoIf yes, what is the start date?

9. If using Informal Relative Care, what is the relationship of the provider to the child?

Name (Last, First, Middle)

Date of Birth (DOB)

Date

SSN (optional)

Are you Hispanic/Latino? No Yes

Alien Status (if not a citizen): See choices above

1. Is this child receiving Supplemental Security Income (SSI)?

2. What is the child's relationship to you?

3. Does this child have a disability?

4. Does this child receive benefits from Social Security?

5. Have you applied for child support for this child? 3 6. Do you receive child support for this child?

NoIf no, please see instructions on page 6.

7. What is the name of this child's absent parent(s)?

8. Is this child in Head Start?

Yes

NoIf yes, what is the start date?

9. If using Informal Relative Care, what is the relationship of the der to

Name (Last, First, Middle)

Date of Birth (DOB)

Date

SSN (optional)

Are you Hispanic/Latino? No Yes

Alien Status (if not a citizen)

1. Is this child receiving Supplemental Security Income (SSI)?

2.What is the child's relationship to you?

3. Does this child have a disability?

4. Does this child receive benefits from Social Security?

5. Have you applied for child support for this child? 4 6. Do you receive child support for this child?

NoIf no, please see instructions on page 6.

7. What is the name of this child's absent parent(s)?

8. Is this child in Head Start?

No If yes, what is the start date?

9. If using Informal Relative Care, what is the relationship of the provider to the child?

Name (Last, First, Middle)

Date of Birth (DOB)

Date

SSN (optional)

Race

Are you Hispanic/Latino? No Yes

Alien Status (if not a citizen): choices above

1. Is this child receiving Supplemental Security Income (SSI)?

2. What is the child's relationship to you?

3.Does this child have a disability?

4. Does this child receive benefits from Social Security? 5. Have you applied for child support for this child? 5 6. Do you receive child support for this child? 7. What is the name of this child's absent parent(s)? 8. Is this child in Head Start?

NoIf no. please see instructions on page 6. No

No If yes, what is the start date?

9. If using Informal Relative Care, what is the relationship of the provider to the shild?

Section 5 Other Household Members

Name (Last, First, Middle)

SSN (optional)

Are you Hispanic/Latino? No Yes

Alien Status (if not a citizen): See choices below

Permanent Resident Asylee Alien Granted Conditional Parolee (1 yr. or more) Alien Whose Deportation

Child or Parent of Child Undocumented Alen

Refugee Battered Alien Spouse,

Black or African American Native Hawailan or White

Are you Active Military Status? Yes No Adopted Child Biological Child Sibling Stepchild Does household member have an activity that makes them unavailable to care for the child? Does household member have earned or unearned income? 2. Is there a circumstance that makes the household member unable to care for the child?

Relationship to Applicant: See choices below

Primary Language

Relationship to Applicant

Choices for Relationshipto Applicant:

Cousin Foster Care Child Grand/Great Grandchild

Ward Other (Related) Other (Not Related)

Name (Last, First, Middle)

SSN (optional)

Race

Are you Hispanic/Latino? YesNo

Alien Status (if not a citizen): See choices

Are you Active Military Status? YesNo

Primary Language

Relationship to Applicant

Relationship to Applicant: See choices above

Does household member have an activity that makes them unavailable to care for the child? Does household member have earned or unearned income? 2.

Is there a circumstance that makes the household member unable to care for the child?

Name (Last, First, Middle)

SSN (optional)

Race

Are you Hispanic/Latino? No Yes

Alien Status (if not a citizen): See above

Are you Active Military Status? Yes No

Primary Language

Relationship to Applicant: See choices

Relationship to Applicant: See choicesabove

1.Does household member have an activity that makes them unavailable to care for the child? 2.Does household member have earned or unearned income?

Is there a circumstance that makes the household member unable to care for the child? 3.

3. Is there a circumstance that makes the household member unable to care for the child?

Name (Last, First, Middle)

SSN (optional)

Race

Are you Hispanic/Latino? YesNo

Alien Status (if not a citizen): See choices above

Are you Active Military Status? YesNo

Primary Language

Relationship to Applicant

Relationship to Applicant:Seechoicesabove

Does household member have an activity that makes them unavailable to care for the child?

Does household member have earned or unearned income? 2.

Is there a circumstance that makes the household member unable to care for the child?

Activity Type: See choices below

Job Search Community Service Education

Name of Organization

Format: (000) 000-0000.

Name of Organization

Employment Training FIA Personal Responsibility Plan Organization Phone Number:

Organization Address

Street

City

State

Zip Code

If you do not have a standard activity schedule. enter total hours per week

Enter daily commute time from provider to activity (to and from)

Applicant/Household Member Name (from Section 2 or 5)

Activity Type: See choices above

Activity Type

Name of Organization

Organization Address

Street

City

Zip Code

Format: (000) 000-0000.

State

Zip Code

If you don't have a standard activity schedule. enter total hours per week

Enter daily commute time from provider to activity (to and from)

Applicant/Household Member Name (from Section 2 or 5):

Activity Type: See choices above

Applicant/Household Member Name (from Section 2 or 5)

Activity Type

Name of Organization

Organization Address

Street

Zip Code

Format: (000) 000-0000.

City

State

Zip Code

If you do not have a standard activity schedule, enter total hours per week

Enter daily commute time from provider to activity (to and from)

For all activities that are "Employment," you must attach a letter from the employer on company letterhead verifying work hours. Forall activities that are "Education" or "Training," you must attach a copy of the current school/training schedule on school letterhead to verify days and hours of classes.

School Aged Children: If care schedule is not provided, the child will be issued a one unit scholarship (15 hours per week)

If you do not have a standard childcare schedule, enter total hours per week

If you do not have a standard childcare schedule, enter total hours per week: What are the specific days and hours you need childcare each day based on your activity?

If you do not have a standard childcare schedule, enter total hours per week

What are the specific days and hours you need childcare each day based on your activity?

If you do not have a standard childcare schedule, enter total hours per week

What are the specific days and hours you need childcare each day based on your activity?

Name of Household Member with Income

Type of Income: See choices below

Alimony Armed Services Pay Child Support Court Ordered Child Support Voluntary SS Benefits

Tips/Commission Pay Unemployment Gross income eachtime Household Member is paid ($):

Veterans Assistance/Benelit Wage/Salary Workers Compensation Other

1 If the income is Child Support. what is the name of the absent parent paying it?

How often does Household Member receive the income?

Gross income eachtime Household Member is paid ($)

If the income is Child Support. what is the name of the absent parent paying it?

Name of Household Member with Income

Type of Income: See choices above

c How often does Household Member receive the income?

How often does Household Member receive the income?

Gross income on Household Member pay stub ($)

If the income is Child Support, what is the name of the absent parent paying

Name of Household Member with Income

Type of Income: Seechoices above

How often does Household Member receive the income?

Gross income each time Household Member is paid ($)

If the income is Child Support, what is the name of the absent parent paying it?

Name of Household Member with Income

Type of Income: See choices above

c How often does Household Member receive the income?

How often does Household Member receive the income?

Gross income each time Household Member is paid ($)

If the income is Child Support, what is the name of the absent parent paying it?

Attach proof of last 4 weeks of all income for: applicant, spouse, other parent in home, parents of minor parent, adult, and spouse with physical custody of minor child.

Your application gives us information about whether you are eligible for benefits and services These benefits are provided at Lovin Touch Learning Center expense and you must give true information It may be verified with public and private agencies and businesses. As a condition of this Scholarship, you will be required to volunteer at our establishment as an agency will waive for your childcare. Please note, it will be your responsibility to inquire about the hours, time or day and let us know your availability. If you fall to complete your volunteer hours, you will be held responsible for 1 1/2 (one and one half) times the amount of monies extended. For instance, we covered 3 weeks at $200, you fail to volunteer, balanced owed will be $900. Please initial you have read and understand the above statement.

hours, to be determined based on the cost we

Consent to Release Information:

I hereby authorize the Lovin Touch Learning Center, or any entities authorized by LTLC to contact, review, and obtain records maintained by any person, partnership, corporation association, or governmental agency for the purpose of establishing proof of my eligibility for CCS program information by email and/or text message. A photocopy of this form is as valid as the original.

example@example.com

Parent Name Printed

Date

Parent Signature

Date

Other Parent Name (Parent/Spouse in the Household or Parent of Minor Child) Printed

Date

Signature of Other Parent (Parent /Spouse in the Household or Parent of Minor Child)

Date

APPLICATIONS NOT SIGNED AND DATED WILL BE RETURNED.

Electronic signatures are NOT accepted.

Date of application must be within 45 days of submission.

H I L D

MM/DD/YYYY

MM/DD/YYYY

TCA

M E

M E

I N C

M E

O M E