Application For Child Care Fee Subsidy (Page 5 of 5) in pdf

Application For Child Care Fee Subsidy Page 5

J. INFORMATION ON CHILDREN NOT REQUIRING CARE

Last Name:

First Name:

Child’s Date of Birth:

Name of School Attending:

Last Name:

First Name:

Child’s Date of Birth:

Name of School Attending:

K. 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, Child Care Services immediately of any changes in my/our circumstances, such as changes in marital

status, employment, school, training, and/or any other changes in my/our situation. I/we also consent to the

exchange of information between the County of Renfrew Child Care Services and my/our preferred Child Care

Provider choices as well as Ontario Works or Ontario Disability Support Program (if applicable) for the purpose of

determining a placement for my/our child(ren).

Signature of Applicant:__________________________

Date Signed:_____________________________

Signature of Spouse:___________________________

Date Signed:_____________________________

Office Use Only

Telephone Application completed on _______________________by__________________________________.

Applicant(s) have been read, indicated their understanding and provided verbal consent to the above Statement of

Fact and Consent.

Applicant 1

Applicant 2

PLEASE RETURN ALL COMPLETED APPLICATIONS AND DOCUMENTS TO:

County of Renfrew Child Care Services

Attention: Child Care Services Intake Coordinator

Mail: 545 Pembroke Street West

Phone: (613) 732-4100

Pembroke, Ontario

Toll Free: 1-866-561-7679

K8A 5P2

Fax: (613) 732-4437

Email:

childcare@countyofrenfrew.on.ca

Application For Child Care Fee Subsidy Page 5