Dependent Care Travel Award Application
Travel Period
*
Please Select
January 1, 2025 – June 30, 2025
Name
*
First Name
Last Name
Rank
*
Please Select
Assistant
Associate
Full
Email Address
*
School (s)
*
Department (s)
*
Policy Attestations (please check the boxes to confirm):
*
Policy Review: I have reviewed, and I understand the
policies
for this award.
Compliance:
Documentation Requirement
: Documentation of proof of payment (i.e. airline tickets, invoice) will be required.
Deviation Approval
: Deviation from approved activities requires prior approval from Academic Personnel.
Childcare Restrictions
: Funds may not be used to pay immediate family (parents, grandparents, siblings, etc.) for childcare.
Childcare Information:
*
Yes
No
Primary Care Responsibility: Are you responsible for at least 50% of the primary care of the qualifying child?
Additional Childcare Requirement: Childcare is above and beyond any regularly scheduled childcare.
Child's Date of Birth:
*
/
Month
/
Day
Year
Date
Conference/Research Meeting Name:
*
Start Date
*
/
Month
/
Day
Year
Date
End Date
*
/
Month
/
Day
Year
Date
Location (City, State, Country):
*
Add additional conference/research meeting?
Please Select
Yes
No
Conference/Research Meeting #2 Name:
*
Start Date
*
/
Month
/
Day
Year
Date
End Date
*
/
Month
/
Day
Year
Date
Location #2 (City, State, Country):
*
Add additional conference/research meeting?
Please Select
Yes
No
Conference/Research Meeting #3 Name:
*
Start Date
*
/
Month
/
Day
Year
Date
End Date
*
/
Month
/
Day
Year
Date
Location #3 (City, State, Country):
*
Total Amount Requested ($1,000 max):
*
Intended Use of Award and Estimated Expenses:
*
Conference/Research Meeting
Conference/Research Meeting #2, if applicable
Conference/Research Meeting #3, if applicable
Total estimated
Additional childcare
Additional lodging for child and/or
childcare provider
Travel Expenses for child and/or
childcare provider
Other
Please describe how receiving the Dependent Care Travel Award would impact your ability to attend the upcoming conference or research meeting and detail the consequences on your professional activities if this support were not available.
Explain how your participation in the conference/research meeting will benefit your career.
Submit
Clear Form
Updated 11/2024
Should be Empty: