CCAMPIS Application for Services

All information will remain confidential and will be used for eligibility determination, student demographic recordkeeping, needs assessment, federal reporting, and other administrative purposes.

The online application must be completed at one time and cannot be saved.

Student Information
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Information for Service
Education & Academic Need

First-Generation College Status

Disability Status

Consent & Release


To the best of my knowledge, all information provided on this application, including the above eligibility information, is true.


I authorize Child Care Access Means Parents in School to gather my ACT scores, financial aid reports, transcripts, and other necessary information in order to provide me with the services that I have requested, and to make reports to the U.S. Department of Education for the re-funding of this program. I also authorize CCAMPIS to obtain periodic reports from my instructors regarding my academic progress for courses in which I am enrolled. I understand that all information will be kept confidential and will be used for the following specified purposes:

  1. student demographic data & record keeping
  2. federal reporting
  3. program evaluation
  4. other administrative purposes
  5. needs assessment

Please sign in the box below using your mouse or finger if using a mobile or touch screen device.

By typing your name above, you are signing this application electronically.
By typing your name above, you are signing this application electronically.

For more information please email