Application For Child Care Fee Subsidy Page 4
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5I. CHILDREN REQUIRING CARE
CHILD #1
Male
Last Name:
Legal First Name:
Female
Child’s Date of Birth
:
Name of School Attending:
(dd/mmm/yyyy)
Grade:______
JK/SK Schedule (circle)
M T W T F
Child Care/Early Learning/Recreation Program Choices (Please enter up to 3 choices in order of interest)
1.
2.
3.
What type of care is required?
full time
part time
before/after school
summer
(circle days required) M T W T F
Requested Start Date for Child Care:
Day:
Month:
Year:
CHILD #2
Male
Last Name:
Legal First Name:
Female
Child’s Date of Birth
:
Name of School Attending:
Grade:_____
(dd/mmm/yyyy)
JK/SK Schedule (circle)
M T W T F
Child Care/Early Learning/Recreation Program Choices (Please enter up to 3 choices in order of interest)
1.
2.
3.
What type of care is required?
full time
part time
before/after school
summer
(circle days required) M T W T F
Requested Start Date for Child Care:
Day:
Month:
Year:
CHILD #3
Last Name:
Legal First Name:
Male
Female
Child’s Date of Birth
:
Name of School Attending:
Grade:_____
(dd/mmm/yyyy)
JK/SK Schedule (circle)
M T W T F
Child Care/Early Learning/Recreation Program Choices (Please enter up to 3 choices in order of interest)
1.
2.
3.
What type of care is required?
full time
part time
before/after school
summer
(circle days required) M T W T F
Requested Start Date for Child Care:
Day:
Month:
Year:
Do any of your children listed have a Special Need? (select one or more)
My child has a diagnosed special need
Hearing loss
Physical needs
Medical Needs
Autism Spectrum Disorder
Behaviour
Global / Developmental delay
Visual Impairment
Speech / Language delay
Other, specify:
Name(s) of child(ren) with Special Need:
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