Preschool Tuition Assistance

Please also provide the preschool with a copy of your most recent tax return and two most recent pay stubs.
Enrolled Child
Child's Name*
First Last
School Year*
Class*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*

Child's Mother
Mother's Name
First Last
Mother's Date of Birth
Does the mother live with the child?
- Yes
- No
Mother's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Place of Employment
Employed Since
Occupation
Home Phone
Cell Phone
Work Phone
Email
Best Way to Contact?
- Home Phone
- Cell Phone
- Work Phone
- Email

Child's Father
Father's Name
First Last
Father's Date of Birth
Does the father live with the child?
- Yes
- No
Father's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Place of Employment
Employed Since
Occupation
Home Phone
Cell Phone
Work Phone
Email
Best way to contact?
- Home Phone
- Cell Phone
- Work Phone
- Email

Miscellaneous
Have you applied for Child Care Vouchers through mybrightpoint.com?
- Yes
- No
If no, why not? If yes, what is the result?
What amount do you feel you could pay monthly for your child's tuition/child care?
Please briefly describe why tuition assistance is needed for your child at this time and any other information you'd like the tuition/child care assistance team to be aware of:
Certification*
- I certify that the above information is complete and accurate. I understand that suppression of facts, or furnishing misleading/false information, will result in denial of tuition assistance without assigning any reason. All information will be kept confidential.
Signature
Date

Please also provide the preschool with a copy of your most recent tax return and two most recent pay stubs.