Fillable Parent/Guardian 1 Name Parent/Guardian 2 Name Child Information: (Dufferin County)

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Parent/Guardian 1 Name Parent/Guardian 2 Name Child Information: (Dufferin County)

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County of Dufferin - Children's Services
Child Care Fee Subsidy
Recognized Needs Referral Form
_________________________________________________________________
To the referring agency - please fully complete and submit form to the Child Care Fee Subsidy program at:
fax: 519-941-0271 or email: chidcarefeesubsidy@dufferincounty.ca or by mail: 30 Centre Street, Orangeville, ON L9W 2X1
Parent Information:
Parent/Guardian 1 Name Parent/Guardian 2 Name
Child Information: (List only children requiring Subsidized Child Care)
Child 1 Full Name Child 1 Date of Birth
Child 2 Full Name Child 2 Date of Birth
Child 3 Full Name Child 3 Date of Birth
Family Information:
Street Address
City/Province/Postal Code Telephone Number
Reason for Referral:
Child's Need (check all that apply)
Parental Need (check all that apply)
Reason
Suspected
Diagnosed/
Confirmed
Reason
Suspected
Diagnosed/
Confirmed
At-Risk (Abuse or Neglect)
Mental Health
Autism Spectrum
Family Crisis
Developmental Delay
(please describe in notes)
Physical Disability(requires
assistance in caring for child)
Socialization Required
Other (please describe
in notes)
Speech & Language
Other (please describe
in notes)
Notes about Reason for
Referral
Continued....
Continued from page 1
E-mail address
Yes No
Requested
Start Date
End Date
(if known)
Number of Days
Per Week Recommended
Yes No
To the referring agency - please fully complete and submit form to the Child Care Fee Subsidy
program at: fax: 519-941-0271 or email: childcarefeesubsidy@dufferincounty.ca or
mail: 30 Centre Street, Orangeville, ON L9W 2X1
Office Use Only:
Date:
Received Currently in
OCCMS?
Support Plan
How will this
referral
support this
family in their
work with your
agency?
Name of Referring
Agency
Contact Person
Telephone
Number
Have the parent(s) indicated in this
document completed an consent to
share information form with your
agency?
Have the parent(s) indicated been
provided with a Child Care Fee
Subsidy Waitlist Placement Form?
Signature of Person Completing
Referral
Date
Yes No
Submit Form
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ParentGuardian 1 Name ParentGuardian 2 Name Child Information: (Dufferin County)

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Completed 8 April 2021

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