Waiting List
Fields marked with a * are required.
Date
*
-
Month
-
Day
Year
Date Picker Icon
Name
*
First Name
Last Name
Home Phone
*
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
E-mail
*
Child's First and Last Name
First Name
Last Name
Child's Birth Date
*
-
Month
-
Day
Year
Date Picker Icon
Desired Start Date for Child Care
*
-
Month
-
Day
Year
Date Picker Icon
What school does your (or will your) child attend?
School Name
What Grade Will Your Child Be In When Care Is Needed? If Your Child Is Not Enrolled, Please Select N/A
N/A
JK/SK
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Does your child require any of the following services? (Please select all that apply)
*
Behavioural therapy
ErinoakKids
Integration/Inclusion services
Occupational therapy
Physio therapy
Region of Halton Child Care Fee Subsidy
ROCK
Speech and language therapy
Not Applicable
Program
*
Oakville Toddler (2 to 2.5 years)
Oakville Juniors (2.5 to 4 years)
Oakville Before/After Program (JK/SK)
Oakville Before/After Program (6 to 10 years)
Has your child had any child care or group experience?
*
Yes
No
Additional Comments
Where Did You Hear About Us?
Referral From Existing/Former Parent
Referral From Staff Member
Referral From Community Member
Facebook
Internet Search
Other
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform