Impact Aid Parent Survey — Colorado Military Child Hub

Step 1 of 5 — Student Information 20%

Step 1 of 5

Student Information

Please provide information for the student being counted in the Impact Aid survey. Submit a separate form for each child if they attend different schools.

Student First Name *

Required.

Student Last Name *

Required.

Date of Birth *

Required.

Grade Level *

Required.

School Year *

Required.

Survey Date *

Required.

School District *

Required.

District Name *

Required.

School Name *

Required.

Student's Residential Address

Note: P.O. Boxes are not accepted per 34 CFR 222.35. Please provide a physical street address.

Street Address *

Required. No P.O. Boxes.

Unit / Apt / BOQ (if applicable)

City *

Required.

State *

Required.

ZIP Code *

Required.

Does the student reside on federal property (e.g., a military installation)? *

Yes — resides on federal property

No — resides off base

Required.

Name of Federal Property / Installation *

Required.

Step 2 of 5

Parent or Guardian Information

Information about the parent or guardian submitting this survey.

First Name *

Required.

Last Name *

Required.

Relationship to Student *

Required.

Email Address *

Please enter a valid email.

Step 3 of 5

Military & Federal Status

Select the category that applies to the parent or guardian in this household. If more than one applies, select the primary one.

⚠️ National Guard / Reserve Members Guard and Reserve families qualify for Impact Aid only while serving on federal orders (Title 10 active duty) as of the survey date, and documentation of orders is required. If this applies to you, please contact us directly and we will assist you with a paper survey form.

📞 · ✉️ militaryaffairs@aurorachamber.org

Service / Employment Status *

Active Duty
Full-time service member — Army, Navy, Air Force, Marine Corps, Space Force, or Coast Guard

DoD Civilian Employee
Civilian employee of the Department of Defense

Federal Civilian Employee (non-DoD)
Employee of any other federal agency (VA, DHS, USPS, etc.)

Foreign Military Officer / Government Official
Allied nation military officer or government official assigned to a U.S. installation (e.g. Buckley SFB liaison)

Surviving Dependent
Child of a servicemember who died on active duty

Required.

Active Duty Service Member Details

Servicemember Last Name *

Required.

First Name *

Required.

Branch of Service *

Required.

Pay Grade / Rank *

Required.

MOS / AFSC / Rate / Designator * (e.g. 11B, 13S, 68W, 6F0X1, BM, 1310)

Required.

Federal Employment Details

Last Name *

Required.

First Name *

Required.

Federal Agency / Employer *

Required.

Name of Federal Property Where Parent Works *

Required.

Address of Federal Work Location

Street Address *

Required.

Unit / Bldg (if applicable)

City *

Required.

State *

Required.

ZIP *

Required.

Surviving Dependent Information

Last Name of Deceased Servicemember *

Required.

First Name *

Required.

Branch of Service *

Required.

Pay Grade at Time of Death *

Required.

Foreign Military Officer / Government Official Details

Last Name *

Required.

First Name *

Required.

Rank *

Required.

Country of Service *

Required.

Step 4 of 5

Review Your Information

Please review everything below before signing. If anything is incorrect, go back and correct it.

Summary

Step 5 of 5

Certification & Signature

Read the certification statement carefully and sign below.

Certification Statement

I certify that the information provided in this survey is true and accurate to the best of my knowledge. I understand that this information will be used by my child's school district to apply for federal Impact Aid funding under the Elementary and Secondary Education Act (20 U.S.C. § 7701 et seq.) and 34 CFR 222.35. I understand that this survey is voluntary and that my response is confidential. I understand that knowingly providing false information may constitute a federal violation and may affect the district's federal funding.

Electronic Signature *

Sign here →

Please type your full legal name as your signature.

By typing your name, you are providing an electronic signature legally equivalent to a handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN) and Colorado law.

Date *

Required.

I confirm the information above is accurate and I consent to this data being processed by the Aurora Metro Chamber of Commerce as an authorized data processor for my school district, solely for Impact Aid funding calculation under 20 U.S.C. § 7701.

✅

Survey Submitted!

Thank you. Your Impact Aid Survey has been recorded and will be submitted to your school district's Impact Aid coordinator.

Confirmation ID

—

If you provided an email address, a confirmation copy will be sent to you.
If you have children at other schools, please submit another form.

Questions? militaryaffairs@aurorachamber.org

Impact AidParent Survey

Student Information

Parent or Guardian Information

Military & Federal Status

Review Your Information

Certification & Signature

Certification Statement

Survey Submitted!

Impact Aid
Parent Survey