Required fields are marked with asterisks (*)

Child Care Subsidy - General Consent Form for Parents and/or Guardians

This form is for Parents and/or Guardians to provide consent for Child Care Subsidy Staff at the Region of Waterloo to communicate with Child Care Operators, other Early Learning and Child Care Professionals or Community Supports prior to a Child Care Subsidy Application being completed by the Parent and/or Guardian. Information that is exchanged between Child Care Subsidy and Early Learning & Child Care Provider/Professional can include information about a family's eligibility for Child Care Subsidy, a family's application status for Child Care Subsidy and any relevant information related to referring agencies with Child Care Subsidy, as indicated below.

This Consent Form is valid for a period of up to 1 year. Please notify us verbally or in writing if you would like to request changes to the form prior to this date.

Parent and/or Guardian First Name

Parent and/or Guardian Last Name

Second Parent and/or Guardian First Name (Spouse)

Second Parent and/or Guardian Last Name (Spouse)

Address

Postal Code

City

Phone Number

Email Address

Child's First Name

Child's Last Name

Child's Date of Birth

Child's First Name

Child's Last Name

Child's Date of Birth

Child's First Name

Child's Last Name

Child's Date of Birth

General Consent:

I authorize consent to exchange personal information to coordinate my/our child care subsidy application and services for up to 12 months from the date the form is submitted. I acknowledge that Child Care Subsidy staff at the Regional Municipality of Waterloo will exchange information about me/us to staff of Licensed Early Learning and Child Care, Extended Day, Youth Development, Recreation programs, or referring agencies (including special needs resourcing and social assistance) in order to coordinate my/our child care subsidy application and services.

Do you require a language interpreter?

Yes

Preferred Language:

Additional Comments and/or Accommodation Requests:

Acknowledgement: I/we ("the Parents and/or Guardians) authorize consent to exchange personal information as outlined above

Yes, I/we ("the Parents and/or Guardians") authorize consent to exchange personal information to coordinate child care subsidy application and services.

If you have any questions, please contact the Child Care Subsidy Program:

Email: ccs@regionofwaterloo.ca
Phone: 519-575-4400

To apply for Child Care Subsidy please visit: Region of Waterloo: Help Paying for Child Care

Privacy Protection - Notice of Collection:
The personal information you provide in this consent form is collected to process and administer subsidies for Early Learning and Child Care programs and to approve placements at such programs, as allowed under the Child Care and Early Years Act, 2014 S.O. 2014, Chapter 11, Schedule 1 and O. Reg 138/15. Questions about the collection of personal information can be made to the Region of Waterloo’s Child Care Subsidy Manager at CHSAdmin@regionofwaterloo.ca or 519-575-4400. You may click on the Privacy Statement on the Region of Waterloo’s website at www.regionofwaterloo.ca for more information about the Region’s privacy obligations.