Preschool Family Application 2011-2012
Indian Creek Valley Christian Family & Children’s Center Tuition Preschool Grant Program
Form CCS-1
LEVEL YOU ARE APPLYING: Level 1 [ ] Level 2 [ ]
REGISTRATION INFORMATION:
Parent/Guardian’s Name: _____________________________________________________________________________
First Name Middle Initial or Name Last Name
Parent/Guardian’s Name: _____________________________________________________________________________
First Name Middle Initial or Name Last Name
Address:____________________________________City_________________________State:_____Zip:____________
Home Phone:________________________Work Phone:_______________________Other Phone:__________________
PLEASE LIST BELOW ALL CHILDREN APPLYING FOR AN ICVCFCC PRESCHOOL TUITION GRANT PROGRAM. ONLY CHILDREN ENTERING PRESCHOOL ARE ELIGIBLE.
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Child 1 |
Child 2 |
Child 3 |
Child 4 |
Name |
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Date of Birth |
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Gender |
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Relation to Guardian |
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County of Residence |
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Conditions of Eligibility:
Household size (sum of adults and children as reported on the Financial Information Form):____________________
Total 2010 household income (Please see Financial Information Form to determine income):$___________________
An affirmative answer to all the following questions is required for scholarship eligibility
Please put a check in the box to the left of each statement to indicate the statement is true
[ ] I promise to pay my child’s school account in a timely and responsible manner. I understand that failure to stay current with tuition payment will result in the loss of the ICVCFCC Tuition Preschool Grant Program.
[ ] I certify that the above student(s) is a legal resident of the state of Pennsylvania.
[ ] I certify that our family qualifies for the ICVCFCC Tuition Preschool Grant Program according to the income guidelines (attached).
[ ] I certify that the above student(s) is entering Preschool in 2011-2012 at Champion Christian Preschool.
[ ] I promise to ensure at least 90% attendance of my child(ren) or risk the loss of my tuition assistance.
I understand that all of the above conditions must be met by child/family to be eligible for a tuition grant program award. Finally, I agree to release ICVCFCC from any liability in its efforts to provide this tuition assistance.
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Print Name of Parent/Guardian Signature of Parent/Guardian Date
PLEASE PROVIDE THE NAME(S) AND SIGNATURE(S) FOR ANY ADDITIONAL PARENT(S) OR GUARDIAN(S) THAT MAY BE SIGNING REPORTS AT THE SCHOOL.
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Print Name of Parent/Guardian Signature of Parent/Guardian Date
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Print Name of Parent/Guardian Signature of Parent/Guardian Date