RayCam Licensed Childcare Waitlist Intake Form

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Name of Child *

Child's Date of Birth *

YYYY

Parent/guardian's name

Primary address for the child

Phone number for the primary guardian/parent *

Email for primary parent/guardian(if preferred to be contacted via email)

Is this waitlist request for daycare or out of school care? *

Daycare

OSC

If for OSC which school does the child attend?

Strathcona

Seymour

Clear selection

Is the family connected with any programs in the neighborhood? Check all that apply *

RICHER

Sheway

Crabtree

Strongstart

Child/sibling previously or currently enrolled in RayCam licensed childcare

Child/sibling currently or previously enrolled in RayCam All Stars or Family Programming

Other:

Required

Does the child have any extra developmental or behavioral needs? *

What is the reason for care? If the child has two parents/guardians please note the reason for care for both referral? whether each parent/guardian is working, studying, looking for work or has a medical condition? Or do you have a social worker referral? *

Is there anything else you would like for us to know?

Name of person filling out this form *

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