Recognized Need For Child-Care Fee Subsidy printable pdf download

Social Services Department, Children’s Services Division

605 Rossland Rd E., Level 1, P.O. Box 623, Whitby, ON L1N 6A3

Phone: 905-666-6238 ● Toll-free: 1-800-387-0642 ● Fax: 905-666-6220

RECOGNIZED NEED FOR CHILD-CARE FEE SUBSIDY

To be completed by applicant requesting child-care fee subsidy

(please print)

Applicant name:

Applicant date of birth:

Address:

Telephone number:

Name(s) of child(ren) requiring child care:

Child’s date of birth:

I hereby consent to the release of information by ________________________________ to an

(Referring physician or agency)

authorized representative of the Children’s Services Division, The Regional Municipality of Durham.

Applicant signature:

Date:

To be completed by referring physician or agency

(please print)

Name of physician or agency (stamp or/and name, address, telephone number)

Describe the need for child care, as it pertains to the child’s special needs (handicapped

conditions/developmental disability) or the child’s social need. Why does this child require child care?

_______________________________________________________

Describe the need for child care, as it pertains to the parent’s illness or disability. Note, in detail, how the

illness/disability limits their ability to care for the child(ren).

_______________________________________________________

Please state any other considerations that may be relevant in determining this family’s need for child care.

_______________________________________________________

________________

When is child care required? Start date:

End date:

Specify days and hours:

Monday

Tuesday

Wednesday

Thursday

Friday

Part-time (less than six hours)

Full-time (more than six hours)

Physician or agency member signature:

Date:

This information is collected under the legal authority of the Day Nurseries Act for the purpose of administering the services and programs prescribed or

authorized under this Act. Questions or complaints about this collection, use or disclosure should be addressed to the Manager of Children’s Services, Social

Services, The Regional Municipality of Durham at 605 Rossland Rd. E, Whitby ON, L1N 6A3 at 905-668-7711 or toll-free at 1-800-372-1102. If this

information is required in an accessible format, please contact 1-800-372-1102 ext. 2671.

January 2014