EEC Tuition Funding Assistance Waitpool Application

EEC Tuition Funding Assistance Waitpool Application
If you believe that you and your family would qualify for Tuition Funding Assistance, please answer each question to the best of your ability and call Taylor with any questions at 831.459.3396.
Child's First & Last Name *

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Preferred Start Date *

MonthDayYear
Date
Program Request*
UCSC Family Affiliation*
Has your child previously been in group care? Is there anything you'd like to share about your child?
Family Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current/Future Housing Plans*
If you selected other or plan to move in current/future housing plans, please explain
Income Information

Families applying for Tuition Financial Assistance must list all sources of gross monthly income that the family receives. If your family is offered space in the program, you will be required to submit current income documentation prior to enrollment attached at the bottom of this form.

	Parent #1	Parent #2
Wages (monthly gross, including T.A. if applicable)
Calworks/CalFresh cash aid
Child Support
Workers Comp or Disability
Other Income (Specify)

Total Gross Monthly Family Income (w/o Financial Aid & Before Tax Deductions) *
Total Number in your Family Size (only include parents/guardians and children under the age of 18 living in the same home)*
Please upload your income documentation to determine accurate eligibility (last two months of paystubs or deposits preferred) *

Cancelof
Reason for Needing Child Care

In order for your family to qualify for tuition funding support, you must have a full time need for child care. Please answer all questions below regarding your families need for services.
Parent # 1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
In training/education*

YesNo
Full Time/Part Time*

Full Time EnrolledPart Time EnrolledN/A
Name of School*
Undergrad or Grad*

UndergradGraduateN/A
Graduation Date *
Employed*

YesNo
Employment Schedule*

Full TimePart TimeN/A
Other (if applicable)
Parent # 2 (f not applicable, please type N/A)*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
In training/education*

YesNoN/A
Full Time/Part Time*

Full Time EnrolledPart Time EnrolledN/A
Name of School*
Undergrad or Grad*

UndergradGraduateN/A
Graduation Date *
Employed*

YesNoN/A
Employment Schedule*

Full TimePart TimeN/A
Other (if applicable)
Waitlist Pool Waiver
I have read the instructions for completing this form and, to the best of my knowledge, have answered the questions truthfully regarding my affiliation with UCSC, household income and childcare needs.

Families applying for financial assistance must list all sources of gross monthly income that will apply to your family at the time of the application. If your family is offered enrollment, you will be required to submit current income documentation at the time of a potential enrollment space. You must update this information if and when it changes because it may affect your child's placement on the waitlist pool.

All families eligible to be evaluated for financial assistance must demonstrate a need for childcare (full-time student and/or full-time employed).

I understand that it's my responsibility to keep EEC informed of any changes to the above information as it can affect my placement (move up or move down in priority on the waitlist pool).
I have read the above & agree
Photo Release
I hereby grant and authorize undefined the right to take, edit, copy, publish, distribute and make use of any and all pictures or video taken of my child(ren) to be used in and/or for legally promotional materials and digital communications. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of and will not be returned.
I have read the above & agree
On Campus Walks & Field Trip Waiver & Medical Authorization
On-campus walks and field trips provide rich opportunities to learn about the community and the natural world. The teaching staff carefully plans these trips using center policies. Your permission, as completed with your signature, is used for these activities throughout the year. Our transportation for these trips is by foot and campus shuttle loop bus.

In the event that my child should need emergency medical treatment while participating in a field trip or on-site at EEC, I hereby authorize a representative of the UC Regents to use his or her own judgment in obtaining emergency medical care for my child. I further authorize any individual selected by university personnel to render such emergency medical treatment to my child as is deemed necessary and appropriate. I understand the costs of this treatment shall be my sole responsibility.

I understand that I indemnify and hold harmless the UC Regents, its officers, employees, and agents, including volunteers, from any and all claims arising out of or in connection with my child's participation in this activity.

I fully understand that participants are to abide by all rules and regulations governing conduct during the trip. Any violations of these regulations may result in the individual being sent home at the parent's/guardian's expense.

My child has my permission to participate in all on-site and on-campus activities. I understand that activities are carried out under the direction of UCSC Early Education Center.

If I do not want my child to participate in the field trip or is late arriving at the center (after my contracted hours) and misses the field trip, I understand that I will need to provide care for my child during the activity.
I have read the above & agree
Anything else you would like to share or let EEC know?
I have read the instructions of completing this form and to the best of my knowledge answered the questions accurately in regard to income and student/employee status*

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EEC Tuition Funding Assistance Waitpool Application

Income Information

Reason for Needing Child Care

Waitlist Pool Waiver

Photo Release

On Campus Walks & Field Trip Waiver & Medical Authorization