Academic Enrichment Fund Application

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Personal Information

Name

First Name

Last Name

UMass Chan ID Number:

Daytime Phone:

(###)

###

####

Department:

Preferred Email Address:

Home Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Household and Income Details

Number of children in your household:

Number of adults in your household:

Hours worked per week at UMass Chan:

Adjusted gross household income from your last filed tax return (2023 for most people):

Estimated adjusted gross household income for 2024:

If you think your 2024 income will be less than your reported 2023 income from your tax form, please explain why below. Also, please share any information that would help us better understand your income or expenses.

Child's first and last name:

Date of birth:

YYYY

Your Child's Academic Enrichment Arrangement Program Information

Academic Enrichment Program in Which Your Child Participated:

Link to Program Description (if available):

2nd Academic Enrichment Program (if applicable):

Link to 2nd Program Description (if applicable):

3rd Academic Enrichment Program (if applicable):

Link to 3rd Program Description (if applicable):

4th Academic Enrichment Program (if applicable):

Link to 4th Program Description (if applicable):

Description(s) if no link(s) available:

Total Cost of Program(s):

Please submit proof of payment for each program listed to share.childcare@theshareunion.org

VERY IMPORTANT: Please Read and Check Off the Following:

This section is required

I certify that everything in this application is accurate, to the best of my knowledge.

I will provide SHARE with the first page of my most recent 1040 form from my federal tax return. (If you and your partner/spouse report your taxes separately, please include her/his/their 1040 form as well, and write your name at the top so we know to include it with your application).

You can send your tax form and proof of payment of academic program by email to share.childcare@theshareunion.org, fax to 508-929-4040, or mail to SHARE 50 Lake Avenue, Worcester, MA 01604.