Application for Supervised Home Daycare

    A. Personal Information

    Primary Guardian:
    Last Name:
    First Name:
    Street:
    City:
    Postal Code:
    Telephone (H):
    Telephone (W):
    Telephone (C):
    Fax:
    Email Address:
    Work/School Address:
    Transportation: CarBusOther
    Secondary Guardian:
    Last Name:
    First Name:
    Street:
    City:
    Postal Code:
    Telephone (H):
    Telephone (W):
    Telephone (C):
    Fax:
    Email Address:
    Work/School Address:
    Transportation: CarBusOther

    B .Children requiring care

    Child 1: Name:
    D.O.B.:
    Sex: MaleFemale
    Number of days required per week:
    Hours of care:
    School:
    Language(s) spoken:
    Preferred Language of Care:
    Date care Require:
    Please indicate any special needs for care:
    Child 2: Name:
    D.O.B.:
    Sex:: MaleFemale
    Number of days required per week:
    Hours of care:
    School:
    Language(s) spoken:
    Preferred Language of Care:
    Date care Require:
    Please indicate any special needs for care:
    Child 3: Name:
    D.O.B.:
    Sex:: MaleFemale
    Number of days required per week:
    Hours of care:
    School:
    Language(s) spoken:
    Preferred Language of Care:
    Date care Require:
    Please indicate any special needs for care:
    Child 4: Name:
    D.O.B.:
    Sex:: MaleFemale
    Number of days required per week:
    Hours of care:
    School:
    Language(s) spoken:
    Preferred Language of Care:
    Date care Require:
    Please indicate any special needs for care:

    C. Check Appropriate Box

    Full feeSubsidized
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