RayCam Co-Operative Licensed Childcare Waitlist Form
Daycare
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent/ Guardian Name
*
First Name
Last Name
Primary Address of Child
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email for Primary Parent/ Guardian
example@example.com
Phone Number of Parent/Guardian
*
Please enter a valid phone number.
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 previously or currently enrolled in Rec or Family programs at RayCam
Other
Does your child have any developmental or behavioural needs ?
*
What is the reason for care? ( i.e, parent/guardian is working, is in school, has a medical condition, or is there a social worker referral)
*
Is there anything else you would for us to know about your child or family?
Name of person/organization filling out form if different from parent / guardian name
*
Submit
Should be Empty: