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Our Kids Count Application

Applicant Name: *
Member ID:
Applicant D.O.B.: *Date of Birth (d/m/y)
Applicant Telephone #: *
Applicant Full Address: *
Applicant Marital Status:*
Married
Common Law
Separated
Divorced
Single
Income:*
OW
ODSP
Employment
Temporary Care

Gross Taxable Income for Applicant

Applicant Tax assessment attached?*
Yes
No
Applicant Tax assessment on file?*
Yes
No

Gross Taxable Income for Spouse

Spouse Tax assessment attached?
Yes
No
Spouse Tax assessment on file?
Yes
No
Do you receive the Canada Child Benefit?*
Yes
No
Is any family member living in your house a member of one of the following communities?*
First Nations
Inuit
Métis
N/A

Activity or Item for which you are applying

(Child must be under 18 years of age to qualify)

Child #1 Name:
Specify item/activity being applied for/requested:
Type of item/activity
Recreation
Health
Informal Child Care
Child #1 D.O.B.: Date of Birth (d/m/y)
Cost of item/activity: Date of Birth (d/m/y)
Verification of Cost attached?
Yes
No
Child #2 Name:
Specify item/activity being applied for/requested:
Type of item/activity
Recreation
Health
Informal Child Care
Child #2 D.O.B.: Date of Birth (d/m/y)
Cost of item/activity: Date of Birth (d/m/y)
Verification of Cost attached?
Yes
No
Child #3 Name:
Specify item/activity being applied for/requested:
Type of item/activity
Recreation
Health
Informal Child Care
Child #3 D.O.B.: Date of Birth (d/m/y)
Cost of item/activity: Date of Birth (d/m/y)
Verification of Cost attached?
Yes
No
Child #4 Name:
Specify item/activity being applied for/requested:
Type of item/activity
Recreation
Health
Informal Child Care
Child #4 D.O.B.: Date of Birth (d/m/y)
Cost of item/activity: Date of Birth (d/m/y)
Verification of Cost attached?
Yes
No
Total Requested:
Taxes:

Declaration

Declaration Acceptance: *

I declare the information given here to be accurate and complete.

Applicant Name: *
Date: *Date signed (d/m/y)

Notice with Respect to the Collection of Personal Information

(Freedom of Information and Protection of Privacy Act)

(Municipal Freedom of Information and Protection of Privacy Act)

 

The information is collected under the legal authority of the Day Nurseries Act, R.S.O. 1980, c. 111, for the purpose of ensuring a high quality of delivery of Children's Day Care services operated under the Ontario Government's Day Nursuries Program.

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