Verification for Need for Child Care - Special Needs

Verification for Need for Child Care - Special Needs
Child Care Subsidy
The personal information requested on this form is collected and managed in accordance with the Freedom of Information and Protection of Privacy Act. If you
have any questions about the collection or use of this information, contact your local Child and Family Services Authority.
Section 1 - Information of Individual Being Referred
First Name
Middle Name
Last Name
Address
Section 2 - Authorized Professional
This section must be completed by one of the following individuals (please check the appropriate box):
Medical Doctor
Psychologist
Psychiatrist
Counsellor
Social Worker
Other Qualified Professional (please specify)
Name of Authorized Professional
Agency Name (if applicable)
Business Telephone Number (include area code)
Business Address
parent/guardian
I confirm that the above named
requires child care due to a special need that is:
from
child
emotional
physical
sensory
communication
developmental
to
Start Date (mm/dd/yyyy)
End Date (mm/dd/yyyy)
Authorized Professional's Signature
Date (mm/dd/yyyy)
FOR OFFICE USE ONLY
Date Received (mm/dd/yyyy)
Reviewed By:
Action:
Approved
CS3610 (2009/07)
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