Fillable County of Dufferin - Children's Se Intake Form (Dufferin County)

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County of Dufferin - Children's Se Intake Form (Dufferin County)

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The County of Dufferin - Children's Se Intake Form (Dufferin County) form is 2 pages long and contains:

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  • 19 check-boxes
  • 32 other fields

Country of origin: CANADA
File type: PDF

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County of Dufferin - Children's Se
rvices
Intake Form
for
Child Care Fee Subsidy
What is Child Care Fee Subsidy?
Child care fee subsidy is a program that helps qualifying families cover the cost of licensed child care for children up to
the
age of 12.
Who can apply for Child Care Fee Subsidy?
To apply for child care fee subsidy, you must be:
1) Living in the County of Dufferin
2) A Canadian Citizen, Landed Immigrant or Refugee with a valid work permit or schoolauthorization
3) The parent or legal guardian of a child up to 12 years of age
4) Residing with the child(ren)
Working Parents:
You can apply if you are working full-time or part-time. Care will be approved for scheduled days of employment. To
verify
Employment, you will be required to provide consecutive pay stubs and/or a letter from your employer on
company letter head.
Self-Employed Parents:
You are considered self-employed if you are actively conducting a full-time self-employment activity and you claim
business
expenses against your income. If you are self-employed, please contact the Community Services office to
request a self-
employment application package.
Student Parents:
You must be attending a recognized school or training program on a full-time or part-time basis. Care will be approved
based on
your school schedule each semester. To verify participation, you will be required to provide current verification
of enrollment
and your current timetable.
Special/Exceptional Needs:
Applicants requesting child care fee subsidy for special/exceptional needs will need to have a Child Care Fee Subsidy
Recognized Needs Referral Form completed by a recognized community partner, such as a medical professional,
Community Living Dufferin, Dufferin Child & Family Services, or Wellington-Dufferin-Guelph Public Health. Please
contact the Community Services office to request a Child Care Fee Subsidy Referral Form.
Ontario Works
If you are participating in the Ontario Works Program and require child care, please contact your Ontario Works Case
Worker.
How to apply for Child Care Fee Subsidy
Complete all sections of this form and submit it to the Community Services office with copies of the following
documents:
1) Identification for Parents/Guardians (Canadian Passport or Canadian Birth Certificate or Green Ontario Health Card or
Permanent Resident Card)
2) Identification for Children (Canadian Passport or Canadian Birth Certificate or Green Ontario Health Card or
PermanentResident Card)
3) Federal Income Tax Notice of Assessment (most recent tax year)
4) Canada Child Benefit Notice of Assessment (most recent tax year)
5) Verification of Address (one of the following: mortgage statement, property tax bill, rent receipt or utility bill)
Please note:
Applications cannot be processed without a copy of your federal income tax notice of assessment or your Canada
child benefit
notice of assessment. If you need to order a replacement copy of these documents, please contact
Revenue Canada
at 1-800-387-1193 for Canada Child Benefit notice of assessment and 1-800-959-8281 for federal income tax notice
of assessment.
Please
submit all information to:
County
of Dufferin Community
Services
30 Centre Street Orangeville, Ontario L9W 2X1
Fax:
519-941-0271
Email:
childcarefeesubsidy@dufferincounty.ca
When your documents have been received, you will be contacted by our office via telephone. If your family meets
the initial criteria for child care fee subsidy, a Community Services Worker will schedule an office verification
appointment with you. You may be required to bring additional information with you to your appointment.
Appointments will be scheduled during our office hours of 8:30am - 4:30pm Monday - Friday. While every effort
will be made to accommodate your schedule, it may be necessary for you to take time off work to attend.
Notice with Respect to the Collection of Personal
Information
The personal information collected on this form is collected under the authority of the Day Nurseries Act, R.S.O.
1990, c. D.2
and will be used for the purpose of determining eligibility for child care fee subsidy in the County of
Dufferin. Specific questions relating to the Municipal Freedom of Information and Privacy Protection Act should be
addressed to the County of Dufferin Clerk at 519-941-2816 ext
2503.
County
of
Dufferin
-
Children's
Services
Intake Form for Child Care Fee Subsidy
Last Name Date of Birth
Town Postal Code
1)Parent/Guardian Information (Applicant 1)
First Name
Address
Phone
Email
Separated Married Widowed
Marital Status (Check One) Single Common Law
If you have selected Common Law or Married, please complete selection for Applicant 2 below.
Last Name Date of Birth
Town Postal Code
2) Parent/Guardian Information (Applicant 2)
First Name
Address
Phone
Email
Yes No
Relationship
3) Are there any other adults living in the home?
Name
Name Relationship
4)
Reason for Applying for Child Care Fee Subsidy - Check all that apply:
Applicant 1:
Working Part Time
Attending School Part Time
Self Employed
Special/Exceptional Needs Referral
Working Part Time
Attending School Part Time
Self Employed
Special/Exceptional Needs Referral
Working Full Time Monday - Friday
Attending School Full Time
Name of Employer or School or Referring Agency
Applicant 2:
Working Full Time Monday - Friday
Attending School Full Time
Name of Employer or School or Referring Agency
5)
Child(ren) Requiring Child
Care
First Name
Last
Name
Date
of Birth
First
Name
Last
Name
Date
of Birth
First
Name
Last
Name
Date
of Birth
Your Completed Application Must Include Copies
of:
Identification
for
Adults &
Children
Verification
of Address
Federal Income Tax Notice
of Assessment
Canada Child Benefit Notice
of
Assessment
Client Declaration:
All of the
information
on
this application is
true to the
best
of
my/our
knowledge.
I/we will inform the
County
of
Dufferin Community
Services
office immediately
of
any changes
in
circumstances such
as,
but not limited
to
change
in
marital status, employment, school
enrollment or
contact
information.
Office
Stamp
Signature Applicant
1
Signature Applicant
2
Date
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County of Dufferin - Children's Se Intake Form (Dufferin County)

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Completed 8 April 2021

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