The Graduate School
Dependent Care Grant Application
Ms. or Mr. Name:
last first mi
Degree Sought: PhD ; MFA Student ID (see below)[*]: _________________________________________
Required
Department/Program: ____________________Amount requested: $ _________________________
Number and street: _________________________________________________________________________
City and state: __________________________________________________ Zip: __________________
Daytime phone number: ___________________________________ E-mail: ______________________
Professional Development Event Title and Dates: ________________________________________________
_____________________________________________________________________________________________
Type of Child/Dependency Care to be subsidized: _____________________________________________________
_____________________________________________________________________________________________
Name(s) and date of birth of dependent(s); relation of dependent(s) to caregiver: _______________________________________________________________
Have you applied for a Child Care Grant before? Yes No
Are you also applying for a Conference Travel Grant ? Yes No
If I receive a Dependent Care Grant, I certify that the funds will be used only to pay for the dependent care described above. The information in this application is correct and complete to the best of my knowledge. I acknowledge that any false information provided in this application may subject me to discipline, up to and including exclusion from The Graduate School.
Date: Signature:__________________________________________________________________
Please include:
1) A brief description (1-2 pages) of the professional development event you are participating in.
2) A Child Care (or dependency) budget.
[*] Student ID is not your Social Security Number. To find your Student ID log in to CAESAR at www.registrar.northwestern.edu and click on “View my Student ID.” It’s a 7 digit number beginning with 1 or 2.