application for child care fee subsidy for licensed home ... · eligibility for child care fee...

Application for Child Care Fee Subsidy For Licensed Home Day Care Services and Child Care Centres

Section 1: Applicant Information Applicant 1 Mother □ Father □ Guardian □

Last Name: First Name:

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

Marital Status: Single □ Married □ Common Law □ Separated/Divorced □ Co-Resident □

Person with legal custody (separated or divorced):

Address: Apt. #:

City: Postal Code: Township:

Home Phone #: Cell #:

What type of transportation do you use: Car □ Public Transit □ Walk □

Preferred language of written communication English □ French □

Applicant 2 (if applicable) Mother □ Father □ Guardian □

Last Name: First Name:

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

Other Adults Living in the Home Yes □ (please specify): No: □ Name: Relationship:

Name: Relationship:

Section 2: Application History Have you applied for child care fee subsidy with our agency in the past? Yes □ No □

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Is your child(ren) attending a licensed child care centre or an approved home child care? Yes □ No □ If yes, name of child care centre or approved home child care provider:

Section 3: Reason for Child Care Applicant 1 Reason for Child Care Fee Subsidy Application Employment □ School □ Training □ Self Employment □ Other □ (please specify):

Work/Training Information Company Name (if applicable): Telephone # & Ext. (Work):

Full time □ Part time □ Casual □ Self Employed □ Start Date:

Please specify days and hours of work/training Monday from to Tuesday from to

Wednesday from to Thursday from to

Friday from to Saturday from to

Sunday from to Shift Work Schedule/On Call □ (please specify):

School Information School Name (if applicable): Telephone # & Ext:

Full time □ Part time □ Start Date:

Please specify days and hours of school Monday From To Tuesday From To

Wednesday From To Thursday From To

Friday From To

Special Needs Special Needs (child) □ Special Needs (parent) □

Applicant 2 Reason for Child Care Fee Subsidy Application Employment □ School □ Training □ Self Employment □ Other □ (please specify): Work/Training Information

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Company Name (if applicable): Telephone # & Ext(work):

Full time □ Part time □ Casual □ Self Employed □ Start Date:

Please specify days and hours of work/training Monday from to Tuesday from to

Wednesday from to Thursday from to

Friday from to Saturday from to

Sunday from to Shift Work Schedule/On Call □ (please specify):

School Information School Name (if applicable): Telephone # & Ext:

Full time □ Part time □ Start Date:

Please specify days and hours of school Monday From To Tuesday From To

Wednesday From To Thursday From To

Friday From To

Section 4: Children Requiring Child Care Child 1 Last Name: First Name: Female □ Male □

Child’s Date of Birth (dd/mm/yyyy):

Name of School Attending: Grade: JK/SK Schedule

M □ T □ W □ T □ F □ What type of child care is required? Full Time □ Part Time □ Before School □ After School □ Before & After School □ Which days of the week is child care required: M □ T □ W □ T □ F □ S □ S □

Requested start date for child care (dd/mm/yyyy):

Drop off time for care: Pick-up time:

Does your child have special needs, health concerns and/or allergies (please specify):

Language(s) spoken in your home:

Would you prefer a pet free home? Yes □ No □

Child 2

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Last Name: First Name: Female □ Male □



M T W T F What type of child care is required? Full Time □ Part Time □ Before School □ After School □ Before & After School □ Which days of the week is child care required: M □ T □ W □ T □ F □ S □ S □


Child 3 Last Name: First Name: Female □ Male □



M □ T □ W □ T □ F □ What type of child care is required? Full Time □ Part Time □ Before School □ After School □ Before & After School □ Which days of the week is child care required: M □ T □ W □ T □ F □ S □ S □


Other Children Not Requiring Child Care Last Name: First Name: Date of Birth (dd/mm/yyyy):

Last Name: First Name: Date of Birth (dd/mm/yyyy):

Last Name: First Name: Date of Birth (dd/mm/yyyy):

Section 5: INCOME INFORMATION

Net Family Income: $ Eligibility for child care fee subsidy is based on the net family income as shown on line 236 of your most recent Income Tax Return (Federal Notice of Assessment or Canada Child Tax Benefit).

Please note that we will do a follow-up at which time you will be required to provide our office with your most recent Canada Child Tax Benefit or Notice of Assessment. Your application cannot be processed without this information. If you have misplaced your Canada Child Tax Benefit, contact the Canada Revenue Agency at 1-800-387-1193 to obtain a copy.

All of the information on this application is true to the best of my/our knowledge and belief. I/We will inform the City of Cornwall Child Care Division immediately of any changes in

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my/our circumstances, such as but not limited to, 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 City of Cornwall Child Care Division and my/our preferred Child Care Provider choices as well as the Ontario Works or Ontario Disability Support Program (if applicable) for the purpose of determining a placement for my/our child(ren). Signature of Applicant #1: Date Signed:

Signature of Applicant #2: Date Signed:

PLEASE RETURN ALL COMPLETED APPLICATIONS TO: City of Cornwall Child Care Division

Mail: P.O. Box 877 Fax: 613-930-7454 Drop Off: Social Services Form Deposit Cornwall, ON Drop Off Box K6H 5T9 340 Pitt Street, Cornwall (Outside main front door)

If you have any question while completing this form, a Child Care Services staff would be happy to assist you. The phone number is 613-933-6282 ext. 3310. Please notify the Child Care Services Division of any changes to your contact information.

Office Use Only

Date received:

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application for child care fee subsidy for licensed home ... · eligibility for child care fee...

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