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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