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 #

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

By selecting this, you are verifying that you have uploaded three (3) of your most recent paystubs OR a Letter of Employment.

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."