Home Child Care Supplementary Payment Application Form (G-Rates) Who is your Child Care Advisor? *Please select your Child Care Advisor...ClairHediKatyeMargaretMeganSandraI don't knowIf you are unsure, please select 'I don't know'.Child First Name *Child Last Name *Child Date of BirthParent/Guardian First Name *Parent/Guardian Last Name *Why do you need extra care?My child has diagnosed special/medical needs.We require extended hours of care (early, late, weekends etc.)Select all that apply.Please describe your child's needs.Please attach a copy of your child's diagnosis here.Choose FileNo file chosenDelete uploaded fileWhen do you need care?Before 6:30amAfter 6:00pmAfter 7:00pmOvernightSaturday and/or SundayMore than 4 hours per day (for school-aged children)More than 10 hours per day (for children who attend full days)Please select all that apply.Please describe your work/school scheduleHas your childcare provider agreed to the extra hours?YesNoIs the provider with you as you complete this form?YesNoCheck yes if the provider is standing beside you. This will allow the provider to sign the form at the same time as you. Otherwise, we will send the form to them separately.Please attach a copy of your work/school scheduleChoose FileNo file chosenDelete uploaded fileYou must justify your request with a school schedule, work schedule, or letter from your employer.Have you submitted this information to your City of Ottawa Subsidy Coordinator for approval?NoYesWhat is the name of your City of Ottawa Subsidy Coordinator?Leave blank if unknown.Do we have your permission to submit this information to the City of Ottawa Subsidy Office on your behalf?YesNoDate the special hours/care beginsIf they already began, please select the date it started.Applicant/Parent Signature *Start signing hereYour browser does not support e-Signature field.Child Care Provider SignatureStart signing your signature hereYour browser does not support e-Signature field.Date: *SubmitPlease do not fill in this field.