Client Information Update

Scholarship Child Name (First & Last)

Parent / Guardian Name (First & Last)

Confirm Contact Information

Phone

Street Address

City

Zip Code

Name of center / provider

Is this a new childcare provider?

Yes

Childcare Provider's Email

Childcare Provider's Phone #

Classroom Name (if applicable)

Classroom Teacher (if applicable)

Current Tuition Rate

Three (3) of your MOST RECENT paystubs for EACH JOB contributing to household income

Letter of Employment (if applicable) Needs to state: rate of pay AND expected hours worked per week

Child Support (direct or indirect)

Amount received MONTHLY:

DCF Child Care Subsidy

Amount received MONTHLY:

Discount / Tuition Reduction

Amount received MONTHLY:

Any other assistance with childcare

Amount received MONTHLY:

If you have any other assistance not listed above, please specify here:

Enrollment Verification

Name of school / institution

Select an option

Upload legal separation, divorce decree, etc.

EX: new spouse / live-in partner, adoption, pregnant / expecting, etc.

Any other changes you are wanting us to be aware of:

By selecting this checkbox and submitting this form, you are agreeing to the following statement:

"I certify that the information listed above is accurate to the best of my knowledge."