Required fields are marked with asterisks (*)

Licensed Home Child Care Application

Child #1

Last Name:

Legal First Name:

Date of Birth: (dd/mm/yyyy):

Licensed Home Child Care Choices

We do not currently have licensed homes in all municipalities listed. Please check off any/all that you would be willing to travel to for care.

Is there a specific Licensed Home Provider you are requesting? If so, which one?

Requested Start Date for Child Care (dd/mm/yyyy):

Drop off time needed:

Pick up time needed:

Does anything listed below apply to your child(ren)? (select all that apply)

Medical Needs

Physical Support Needs

Developmental Delay (diagnosed or suspected)

Speech/Language delay

Hearing Loss

Visual Impairment

Allergies or special diet

Other

PLEASE NOTE: Fee Subsidy and County of Renfrew Licensed Home Child Care are two separate waitlists. If you have not applied for Fee Subsidy, and would like to know more about the Fee Subsidy Program and how to apply, check the box below.

Check here if you would like us to email you Fee Subsidy information when we have confirmed you have been added to our waitlist

Primary Parent/Guardian Information

Surname

Legal First Name

Relationship to Child

Address

City/Town

Postal Code

Primary Phone

Secondary Phone (if applicable)

Email Address

Secondary Parent/Guardian Information

Surname

Legal First Name

Relationship to Child

Address

City/Town

Postal Code

Primary Phone

Secondary Phone (if applicable)

Email Address

Is there any other information you would like us to know about your child(ren)?

STATEMENT OF FACT AND CONSENT

All of the information on this application is true to the best of my/our knowledge and belief. I/we will inform County of Renfrew, Childrens Services immediately of any changes in my/our circumstances, such as address/ contact information, child care choices, start date, and/or any other changes in my/our situation.

I confirm and agree with the above statement.

Agree

Signature Date (dd/mm/yyyy):

Signature

Clear

Signature

Clear