For Office Use Only
App No:
Form Complete
Date Received
____/____/____
Documents Provided
Date Reactivated ____/____/_____
STUDENT ASSISTANCE FUND 2014/2015
SUPPLEMENTARY CHILDCARE APPLICATION FORM
(To be submitted in addition to the SAF Application Form)
First Name
Surname
Student ID
Campus
Total No. of
Children
Name(s) of
Child/Children
Preschool Age
Age
In National
School
In Secondary
School
In Third Level
Education
Name & Address of Creche, Registered Childminder,
Preschool or After School
Cost Per
Month
Letter from Childcare Provider(s) indicating name(s) of child/children and cost per month
must be provided with this application along with copies of children’s birth certs.
ADDITIONAL RELEVANT INFORMATION
ELIGIBILITY CRITERIA
Please note the following are INELIGIBLE for Childcare Support
 Students whose partner/spouse is not engaged in employment or full-time education
 Students whose children have places in Community Creches or who have Government
Subvention places in Creches/Preschools
 Students whose children are with Non-Registered Childminders.
DECLARATION
I declare that all the information provided is true, complete and accurate and that assistance from
other sources has not been received for the stated purpose/service which is the subject of this
application.
Furthermore, I agree to provide sufficient receipts under the relevant funding headings which I
receive funding for.
I agree that all funding received will be used for the purpose intended.
Signature:
_______________________________
Date: __________________________
Please Note:
Students who abuse the fund, or intentionally falsify information, will be the subject of disciplinary
proceedings as outlined in the GMIT Code of Student Conduct
Should a student be paid SAF funding in error, the student will be required to refund the amount of
the payment.
E.S.F. FUNDED
TO APPLY
The fully completed Supplementary Childcare Application Form must be submitted in addition to the
completed SAF Application Form and its required back-up documents to:
SAF Administrator, Student Services, GMIT, Dublin Rd, Galway
or alternatively
Student Services Administrator in the Mayo Campus
Administrators in the College for the Creative Arts & Media
Administrator in the National Centre for Excellence in Furniture Design & Technology, Letterfrack.
FOR OFFICE USE ONLY
Assessed By (initials):
No of Children to be considered
Total Childcare Cost per month
Eligible
Yes/No
€
Exceptional Circumstances
Yes/No
Total Childcare Cost per academic €
year (8 months)
Calculated Rate of
Payment
BACK UP DOCUMENTATION SELF CHECK LIST
€