Today’s Date: ______
APPLICATION FOR METROKIDS SCHOLARSHIP PROGRAM
Note: This application must be filled out completely and all attachments submitted to be considered for a scholarship.
Applicant Name: ______
LastFirst
Applicant Name: ______
LastFirst
Name(s) of children you wish to enroll or are enrolled in the program:
- ______Birthdate______
- ______Birthdate ______
- ______Birthdate ______
How many days of care are you requesting?
______Circle the days you will need: M T W TH F
Address: ______
Street
______
CityStateZip Code
Telephone Number: ______
Alternative Telephone Number ______
Email Address: ______
What is the best way to contact you? ______
Number of people living at the address above: ______
How many of these individuals have an income? ______
List the members of your household that have an income: ______
______
______
Please attach the following to your application:
A recent check stub for each individualwith an income in your household.
A letter from your county of residence verifying the status of your attempt to obtain assistance though the Child Care Assistance Program.
A rough monthly budget of household expenses.
Number of dependents living at the address above: ______
What is your annual household income? ______
*attach the most recent check stub for each individual with an income to this application.
Applicant One:
Average house worked per week: ______Hourly Pay Rate: ______
Do you receive any other form of compensation from your employer such as tips, housing allowance, etc? ______If yes, what is the weekly amount? ______
Do you receive child support or alimony? ______If yes, what is the amount? ______
Are you enrolled in school/college? ______
Is yes, what school/college are you attending? ______
Signature of Applicant 1: ______
Date: ______
Applicant Two:
Average hours worked per week: ______Hourly Pay Rate: ______
Do you receive any other form of compensation from your employer such as tips, housing
allowance, etc? ______If yes, what is the weekly amount? ______
Are you enrolled in school/college? ______
If yes, what school/college are you attending? ______
Signature of Applicant 2: ______
Date: ______
Have you inquired about child care assistance through other sources? ______
You are required to apply for the Child Care Assistance Program through your county of residence before being considered for a scholarship at MetroKids. Have you done so? ______
*Attach verification of your attempt to apply for the Child Care Assistance Program. (Rejection letter, confirmation of name on waiting list, etc.)
Please use the space provided below to tell us why you would like to use our scholarship funds and how these funds will benefit your family.
A MetroKids Scholarship will help me…
Please allow two weeks for processing.
For office use only on this page:
Date Application Received: ______
Scholarship % ______
Weekly Tuition with Scholarship ______
Start date of Scholarship ______