SOCIAL / SPECIAL NEEDS REFERRAL CHILD CARE FEE SUBSIDY APPLICATION TBDSSAB Client Services Division

This form is to be completed by a health or social services professional currently working with this household. The information provided will be used to determine eligibility for fee subsidy for families who are not currently working or attending school. A Special Needs Child is defined as one who has a physical or mental impairment that is likely to continue for a prolonged period of time and who as a result thereof is limited in activities pertaining to normal living as verified by objective psychological or medical findings and includes a child with a developmental disability. Updates: Updates to the Social/Special Needs Referral are required yearly unless it is a child diagnosed with Special Needs. Special Needs referrals do not require updates. Application needs to be completed in full to be considered for approval
Applicant Information
Parent/Guardian(s) Full Name(s) 1)	Address	Phone Number(s)
2)
Full Name of Child	Date of Birth (M/D/Y)
Full Name of Child	Date of Birth (M/D/Y)
Has family secured a space at a Child Care Centre? Yes No 1) Name of Centre: If family has not secured a space, please direct family to go to www.thunderbaychildcare.ca to place their name on the waitlist for the Centre(s) of their choice.
When will family require child care: Start Date: End Date:	Full Days Half Days Mon Tues Wed Thurs Fri
Does the child have a diagnosed Special Need? (ex. Autism, Cerebral Palsy, ADHD, Down Syndrome, etc.) Yes No If yes, please attach a copy of the assessment. Please specify:
Reason for Referral: What are the child/family circumstances and how will placement in a Child Care Centre assist the parent and/or child?
What are the specific needs of this child? (Please attach available medical/third-party assessments and indicate other services the parent(s)/caregiver(s) is/are currently accessing.)

Treatment Plan: What services, treatment, and resources is the parent/child currently receiving?
Enhanced Program Support: Will this child require enhanced program support (individualized support) to attend the child care program?
Continuum of Care Plan: Describe your plan for continued involvement/case management with this family.
Please indicate which community resources you have explored for this family. George Jeffrey Children’s Centre Children’s Centre Thunder Bay Health Unit: Preschool Communication Services Children’s Aid Society Healthy Babies / Healthy Children Dilico Fair Start Wesway Other _____________________________
_____________________________________ _______________________________ ________________ Name of Referring Agency Contact Phone Number Fax ______________________________________ _______________________________ ________________ Contact Name (Please Print) Contact Signature Date
CONSENT TO RELEASE and/or COLLECT INFORMATION (To be Completed by Parent/Guardian)
I/We consent to the collection, use and disclosure of personal information relevant to the above-named child, to and/or from child care programs, home child care providers, referring agencies, The District of Thunder Bay Social Services Children’s Services Division, and Ministries that provide funding / resources / services. I / we _________________________________________________________________________________________________________ Name of Parent(s)/Guardian(s) I in accordance with Section 31 (a) and 31 (b) of the Municipal Freedom of Information and Protection of Privacy Act, hereby authorize and direct ______________________________________________________________ to release Name of Agency to The District of Thunder Bay Social Services Administration Board, Children’s Services, the information requested. The following agencies or persons are not to be included: ________________________________ __________________________ __________________________ Signature of Parent/Guardian Relationship to Child Date _ ________________________________ __________________________ __________________________ Signature of Parent/Guardian Relationship to Child Date
Please forward ALL referrals to the Central Intake Fax at: (807) 345-7921 For child care programs in: Geraldton, Longlac, Manitouwadge, Marathon, Nakina, Nipigon, Schreiber, Terrace Bay, Thunder Bay