Home Child Care Supplementary Payment Application Form (G-Rates)

Who is your Child Care Advisor (if unsure, select "I don't know")? *

Child First Name *

Child Last Name *

Child Date of Birth

Parent/Guardian First Name *

Parent/Guardian Last Name *

Child Care Information

Please complete all required fields.

Why do you need extra care (please select all that apply)?My child has diagnosed special/medical needs.We require extended hours of care (early, late, weekends etc.)

Please describe your child's needs.

Please attach a copy of your child's diagnosis here.

No file chosen

When do you need care (please select all that apply)?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 describe your work/school schedule

Has your childcare provider agreed to the extra hours?YesNo

Is the provider with you as you complete this form?YesNo

Check 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 schedule

No file chosen

You 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?NoYes

What 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?YesNo

Date the special hours/care begins

If they already began, please select the date it started.

Applicant/Parent Signature *

Child Care Provider Signature

Date: *

Home Child Care Supplementary Payment Application Form (G-Rates)

Form Overview

Child Care Information

Please complete all required fields.