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Child Care Application Form

Personal Information

Applicant First Name:*
Applicant Last Name:*
Applicant Previous Names:
Applicant Gender:*
Male
Female
Unknown
Applicant D.O.B (d/m/y):*
Applicant SIN #:*
Applicant Home Address:*
Applicant Telephone #:*
Applicant Email Address:*
Applicant Marital Status:*
Single
Separated
Married
Common-Law
Widowed

Co-Applicant First Name:
Co-Applicant Last Name:
Co-Applicant Previous Names:
Co-Applicant Gender:
Male
Female
Unknown
Co-Applicant D.O.B (d/m/y):
Co-Applicant SIN #:
Co-Applicant Home Address (if different):
Co-Applicant Telephone #:
Co-Applicant Email Address:

Is any family member living in your house a member of one of the following communities?*
First Nations
Inuit
Métis
N/A

Reason for Care:*

Employed/Employer Name:
Work Telephone #:
Student Name:
School Name:
Social Therapeutic:
Referring Agency:
Other:

List all children living with you (ages 0 to 12 years):

Child #1 First Name:
Child #1 Last Name:
Child #1 D.O.B. (d/m/y):
Child #1 Gender:
Child #1 Grade Level:
Child #1 School:
Child #1 needs child care?
Yes
No

Child #2 First Name:
Child #2 Last Name:
Child #2 D.O.B. (d/m/y):
Child #2 Gender:
Child #2 Grade Level:
Child #2 School:
Child #2 needs child care?
Yes
No

Child #3 First Name:
Child #3 Last Name:
Child #3 D.O.B. (d/m/y):
Child #3 Gender:
Child #3 Grade Level:
Child #3 School:
Child #3 needs child care?
Yes
No

Child #4 First Name:
Child #4 Last Name:
Child #4 D.O.B. (d/m/y):
Child #4 Gender:
Child #4 Grade Level:
Child #4 School:
Child #4 needs child care?
Yes
No

Child #5 First Name:
Child #5 Last Name:
Child #5 D.O.B. (d/m/y):
Child #5 Gender:
Child #5 Grade Level:
Child #5 School:
Child #5 needs child care?
Yes
No

Additional Information

Do any of your children requiring child care have a Special Need(s)?
Yes
No
If yes, which children:
Have you already registered your child?
Yes
No

Income Verification

***Assets and general expenses are not considered***

Are you in receipt of Ontario Works?*
Yes
No
Are you in receipt of ODSP?*
Yes
No
Other income sources - Type:*
Either the Notice of Assessment (NOA) or the Canada Child Tax Benefit report for the most recent year can be used to calculate your household annual income* (attach a copy).
Applicant Total Annual Income (Notice of Assessment or Canada Child Care Tax Benefit - line 236) [x]*
Co-Applicant Total Annual Income (Notice of Assessment or Canada Child Care Tax Benefit - line 236) [y]*
Total Annual Income (Notice of Assessment or Canada Child Care Tax Benefit - line 236) [x+y]*
*If you or your child have a disability, please ask if any of your disability-related expenses qualify for a reduction in annual income.

Declaration

Declaration Acceptance:*

All the information on this application is true to the best of my/our knowledge and belief.

 

I/we will inform the Manitoulin-Sudbury DSB immediately of any changes in my/our circumstances, such as changes in marital status, employment, school, training and/or any changes in my/our situation.

 

I will also immediately inform the DSB if either me or my spouse's income increases or decreases by 20% over the duration of the year.

 

I allow the DSB to give the information on this form and any attachments to share within the DSB offices with Ontario Works or Social Housing Departments without further notice to me, if the information is necessary for the purpose of making decisions or verifying eligibility for assistance under the Day Nurseries Act, Housing Services Act 2011, the Ontario Works Act 1997, or the Ontario Disability Support Program Act 1997. 

Applicant Name:*
Date (d/m/y):*
Co-Applicant Name:
Date (d/m/y):

As applicable, please attach copies of the following with your application.

For Family Information:

  • Birth Certificate for all children
  • Social Insurance Cards for parents
  • For parents attending school - proof of school attendance/enrollment
  • For parents working - proof of employment/recent pay stube
  • Social or therapuetic referral verification/letter/document
  • Custody papers, separation agreement or court order

For Income Verfication:

  • Most recent Notice of Assessment
  • Most recent Canada Child Tax Benefit

Send copies of above required documents by:

Fax: (705) 862-7805 or (866) 397-3334
Mail: 210 Mead Blvd., Espanola ON P5E 1R9
Email: childcareapplications@msdsb.net

I will be sending the above required documents by:*
Fax
Mail
Email
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