Required fields are marked with asterisks (*)

Request for Review of Child Care Subsidy

This form is for parents to request a review of a decision to discontinue or deny Child Care Subsidy assistance.

Name

Address

Postal Code

City

Telephone

Date of Birth

When was the decision was made?

Please explain why you disagree with the decision.

Today's Date

Please sign (hold the left button down on the mouse to write your name)

Clear

Thank you for your request.

This form will automatically be submitted to:

Internal Review and Appeals Specialist, Strategic and Quality Initiatives

Region of Waterloo

Community Services

99 Regina St. South, 5^th Floor

Waterloo, ON N2J 4G6

(Fax) 519-883-0152