Child Care Request Form

We can help in your search for Licensed Home Child Care for your child in the County of Lanark. Please complete the child care request form to start the process.

First & Last Name

Address

Phone/Cell

When do you need care to begin? dd/mm/yyyy

In what location do you require child care?

If you selected other, please specify location:

Name of Child (1)

Date of Birth

Name of Child (2)

Date of Birth

Additional children (please add their name and date of birth dd/mm/yyyy)

Does your child(ren) attend school?

Yes No

Enter School:

How many days a week do you need care?

What time would you drop your child off at the child care provider's home?

What time would you pick your child up from the child care provider's home?

If your drop off time changes, what would be the earliest time you would drop your child off?

If your pick up time changes, what would be the latest time you would pick up your child?

Other comments/information:

Childcare Request Form

Child Care Request Form

Child Care Request Form

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