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G
overnment of Newfoundland and Labrador
Department of Education
Child Care Subsidy Funding Application
Early Learning and Child Development Division
Please Note
Supporting documents should be attached to the application – if this is not possible documents may be submitted within 30 days
and must be present for the application to be processed.
Section A – Applicant Information
� New - Initial �
Renewal
Name of parent/guardian Date of Birth
(YYYY-MM-DD)
Street Address
City/Town
Province Postal Code
Mailing Address (if different from above) City/Town
Province
Postal Code
Home Ph. # Work # Cell # Email Address
Relationship to Child:
□ Mother □ Father □ Legal Guardian � CSSD Social Worker □ Kinship Caregiver
Family Status:
□ Married □ Common Law □ Divorced □ Separated □ Widowed □ Single
If divorced or separated, do you have shared custody? □ Yes □ No
If yes to a shared custody, please attach a copy of the written agreement (if applicable).
Number of Children attending a regulated child care service: __________
Section B – Spouse / Partner Information
□ Not Applicable (No Spouse/Partner)
m Name Date of Birth
(YYYY-MM-DD)
Work # Cell # Email Address
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Section C – Children Requiring Child Care
Provide (for each individual child listed below):
A photocopy of Child’s birth certificate, baptismal record or other legal documentation that shows the child’s legal name and date of
birth.
Note: If requiring child care for more than four children, complete an additional Section C and attach it to the application.
Child’s Legal Name: Date of Birth:
(YYYY-MM-DD)
Child Care Requested:
� Full-Time � Part-Time (days of week/time of day needed____________________________________)
� After-School � Before and After-School School-Age (Summer) Coverage
Requested Start Date:
(YYYY-MM-DD)
Name of Regulated Child Care Centre or Regulated Family Home (if known):
Child’s Legal Name: Date of Birth:
(YYYY-MM-DD)
Child Care Requested:
� Full-Time � Part-Time (days of week/time of day needed____________________________________)
� After-School � Before and After-School School-Age (Summer) Coverage
Requested Start Date:
(YYYY-MM-DD)
Name of Regulated Child Care Centre or Regulated Family Home (if known):
Child’s Legal Name: Date of Birth:
(YYYY-MM-DD)
Child Care Requested:
� Full-Time � Part-Time (days of week/time of day needed____________________________________)
� After-School � Before and After-School School-Age (Summer) Coverage
Requested Start Date:
(YYYY-MM-DD)
Name of Regulated Child Care Centre or Regulated Family Home (if known):
Child’s Legal Name: Date of Birth:
(YYYY-MM-DD)
Child Care Requested:
� Full-Time � Part-Time (days of week/time of day needed____________________________________)
� After-School � Before and After-School School-Age (Summer) Coverage
Requested Start Date:
(YYYY-MM-DD)
Name of Regulated Child Care Centre or Regulated Family Home (if known):
Section D – Reason for Requiring Child Care
� Employment (refer to Section E)
� Injury/Illness/Disability/Rehabilitation(refer to sections E & G)
� Education and Training (refer to Sections E & F)
* Intermediate/High School Students omit section E
� Department of Children, Seniors and Social Development – CSSD (refer
to section G)
� Child Development (refer to Sections E & G)
*SCWA omit section E
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Section E – Income Disclosure (for both applicant and spouse/partner – if applicable)
Applicant:
Please answer all questions
Applicant
Net Amount /
Frequency
1. Are you in receipt of income Support?
Provide a copy of:
a. Two current income support pay stubs within last 30 days.
� YES � NO
_________________
2. Are you currently Employed?
Provide a copy of:
a. Canada Revenue Agency Notice of Assessment – Line 236 and a
copy of T2125 (if self-employed).
b. All pay stubs for the last 30 days or a letter from your employer
showing deductions and net pay.
c. A work schedule (if applicable).
� YES � NO
_____________ Weekly
Bi-Weekly
Monthly
Commission
Semi-monthly
3. Are you receiving compensation from Workplace NL?
Provide a copy of:
a. All pay stubs for the last 30 days.
� YES � NO
_____________ Weekly
4. Are you receiving Employment Insurance?
Provide a copy of:
a. All pay stubs for the last 30 days.
� YES � NO
_____________ Weekly
5. Are you receiving a Training Allowance?
Provide a copy of:
a. Stub or letter of breakdown stating net amount (provide after 1
st
payment).
b. Skills Development agreement.
c. Name and phone number of skills development worker.
� YES � NO
___________________
6. Are you receiving Student Aid?
Provide a copy of:
a. Student Loan Notice of Assessment.
b. Program Cost Form.
� YES � NO
__________________
7. Are you receiving/paying spousal support?
Provide a copy of:
a. Legal documentation of spousal support e.g.; support enforcement
agreement with 12 month support enforcement summary, court order (if
applicable).
� YES � NO
_____________ Weekly
8. Are you receiving any other income (e.g.; Canada Pension,
Widow/Widower Allowance, ELCC Supplement, Federal
Assistance Programs)?
Provide a copy of:
a. Verification of any and all sources.
� YES � NO
_____________ Weekly
Bi-Weekly
Monthly
Semi-monthly
Bi-Weekly
Monthly
Sem
i-monthly
Bi-Weekly
Monthly
Semi-
monthly
Bi-Weekly
Monthly
Commission
Semi-
monthly
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Spouse/Partner of Applicant: � Not Applicable
Please answer all questions
Spouse/Partner
of Applicant
Net Amount /
Frequency
1. Are you in receipt of income Support?
Provide a copy of:
a. Two current income support pay stubs within last 30 days.
� YES � NO
______________
2. Are you currently Employed?
Provide a copy of:
a.
Canada Revenue Agency Notice of Assessment – Line 236 and a
copy of T2125 (if self
-employed).
b. All pay stubs for the last 30 days or a letter from your employer
showing deductions and net pay.
c. A work schedule (if applicable).
� YES � NO
_____________ Weekly
Bi-Weekly
Monthly
Commission
Semi-
monthly
3. Are you receiving compensation from Workplace NL?
Provide a copy of:
a. All pay stubs for the last 30 days.
� YES � NO
_____________ Weekly
4. Are you receiving Employment Insurance?
Provide a copy of:
a. All pay stubs for the last 30 days.
� YES � NO
_____________ Weekly
5. Are you receiving a Training Allowance?
Provide a copy of:
a. Stub or letter of breakdown stating net amount (provide after 1
st
payment).
b. Skills Development agreement.
c. Name and phone number of skills development worker.
� YES � NO
___________________
6. Are you receiving Student Aid?
Provide a copy of:
a. Student Loan Notice of Assessment.
b. Program Cost Form.
� YES � NO
___________________
7. Are you receiving/paying spousal support?
Provide a copy of:
a. Legal documentation of spousal support e.g.; support enforcement
agreement with 12 month support enforcement summary, court order (if
applicable).
� YES � NO
_____________ Weekly
8. Are you receiving any other income (e.g.; Canada Pension,
Widow/Widower Allowance, ELCC Supplement, Federal
Assistance Programs)?
Provide a copy of:
a. Verification of any and all sources.
� YES � NO
_____________ Weekly
Bi-Weekly
Monthly
Semi-
monthly
Bi-Weekly
Monthly
Semi-monthly
Bi
-Weekly
Monthly
Semi
-monthly
Bi-Weekly
Monthly
Commission
Semi
-monthly
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Section F – Education/Training
To be completed by the parent(s)/guardian(s) attending a post-secondary institution.
Applicant Spouse/Partner of Applicant (if applicable)
Name of Institution:
Name of Institution:
Semester Start Date: Semester End Date:
(YYYY-MM-DD) (YYYY-MM-DD)
Note: If the program is not semesterised, enter the start and
end date of the program.
Semester Start Date: Semester End Date:
(YYYY-MM-DD) (YYYY-MM-DD)
Note: If the program is not semesterised, enter the start and
end date of the program.
Provide a copy of:
1. Enrollment verification letter from the post-secondary institution outlining:
a. Full-time or part-time studies,
b. Start and end date of course and program,
c. Name, address and contact number for the institution, and
d. Confirmation of enrollment dated the first day of the semester and identifying the length of the semester.
2. A class schedule (to be sent within the first week after the start of scheduled classes).
3. For a student not enrolled in courses but teaching or conducting research (e.g., PhD program) an enrollment verification letter
from the post-secondary institution outlining if the student is enrolled in full-time or part-time studies.
4. Submit financial information as outlined in section E (if applicable).
Section G – Professional Referral
Applicable to applicants who selected either Child Development, Health/Disability of the Parent/Guardian or CSSD as a
Reason for Requiring Child Care in Section D.
Provide a copy of:
1. A Professional Referral, outlining:
a. Details of the child’s or the families need for support,
b. How child care would benefit the child and/or family,
c. Recommended amount of child care services required.
2. CSSD Referral Form (if applicable).
Section H – Consent to Obtain/Disclose Information
I authorize the Department of Education to obtain further information and share appropriate details of my eligibility with
any third party agency, organization and department as necessary for the sole purpose of administration of the Child
Care Subsidy. I am giving this consent of my own free will and I reserve the right to revoke my consent at any time by
contacting a Department of Education delegate in writing and withdrawing my consent. The consent is only valid
between the Department of Education and the person(s) named herein and is valid for one year from the date signed.
Name of person
providing
consent
(please print or type)
Signature
Date
(YYYY-MM-DD)
Name of person
providing
consent
(please print or type)
Signature
Date
(YYYY-MM-DD)
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Section I - Declaration
i. I confirm the information given in this application is, to the best of my knowledge and ability, complete, true and correct.
ii. I confirm that I have read, understood, and agree to the Terms and Conditions of the Child Care Subsidy contained in
Section M.
Parent/Guardian
(please print or type)
Signature
Date
(YYYY-MM-DD)
Parent/Guardian
(please print or type)
Signature
Date
(YYYY-MM-DD)
Section J - Privacy Statement
The information collected on this form is collected under the authority of the Access to Information and Protection of Privacy Act (ATIPPA) and is used
solely for the purposes of administration/operation of the Child Care Subsidy program and services provided by the Early Learning and Child
Development Division. This information is kept confidential and held securely as required by ATIPPA. If you have any questions about the collection or
use of this information, please contact the Policy and Information Management Division of the Department of Education at 709-729-7425.
Section K – Information for Submission
This form may be completed online, but must be printed, signed and submitted (by mail, in person or
electronically) to the regional office in your area.
Regional office information can be found at:
https://www.gov.nl.ca/education/department/contact/#section
PLE
ASE NOTE: Subsidy Applications for Labrador Region are to be sent to Western Regional Office.
Section L – Questions / Inquiries
For general inquires or help in completing your application please contact the regional office in your
area.
Regional office information can be found at:
https://www.gov.nl.ca/education/department/contact/#section
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Section M - Terms and Conditions - Child Care Subsidy
Detach and retain for your records
1. It is the responsibility of the parent/guardian to pay any costs not approved under the Child Care Subsidy program
and to contact the child care service to determine if any such costs apply. Refer to ELCD-2021-SUB-G1 of the
Child Care Subsidy Policy Manual for information on Rates.
2. Applicants are required to report (within 14 days) any changes in the information provided on the subsidy
application by completing and submitting a Change in Circumstance form to the regional office of the Department
of Education, as per the Child Care Subsidy Policy, ELCD-2021-SUB-C1. Failure to notify the regional office of
changes in circumstance may result in an overpayment that must be repaid by the parent/guardian to the child care
service and/or Child Care Subsidy being cancelled.
3. Where the child is removed from the child care service by the parent/guardian permanently, the parent/guardian is
responsible to follow the child care service’s policy on providing notice to that service, and must also notify the
regional office by giving a minimum two week notice. The parent/guardian will be responsible for payment to the
child care service for the period for which notice was not provided. Refer to ELCD-2021-SUB-F1 of the Child Care
Subsidy Policy Manual for information on Notice of Termination.
4. Where Child Care Subsidy funding is approved, an Approval of Child Care Subsidy letter will be sent to the
applicant(s) and an Authorization to Provide Goods/Services form will be sent to the regulated child care service.
Each month the child care service will submit an invoice on behalf of the child, based on the child’s attendance
record. Refer to ELCD-2021-SUB-C1 of the Child Care Subsidy Policy Manual for information on Child Care
Subsidy Approvals.
5. Where the child is absent from the child care service due to illness or any other reason, the parent/guardian must
notify the child care service (NOT the regional office) on the first day of absence. Refer to ELCD-2021-SUB-F1 of
the Child Care Subsidy Policy Manual for information on Attendance.
6. The parent(s)/guardian(s) are responsible for notifying the regional office when a child for whom Child Care
Subsidy has been approved is absent for three consecutive days when the child was scheduled to be in
attendance. Refer to ELCD-2021-SUB-F1 of the Child Care Subsidy Policy Manual for information on Attendance.
7. The Child Care Subsidy Monthly Attendance Records will be reviewed for a child’s attendance at the child care
service. If the Department identifies that there is a pattern of non-attendance, without adequate explanation, it may
result in a review of the approved Child Care Subsidy and possible termination of benefits. Should the Child Care
Subsidy be cancelled, a two-week notice shall will be given in writing to the parent(s)/guardian(s) and the child care
service provider. Refer to ELCD-2021-SUB-F1 of the Child Care Subsidy Policy Manual for information on
Attendance.
8. Parents/guardians are responsible for the choice of regulated child care in which the child participates and
adhering to Child Care Subsidy Polices.
9. Where the above Terms and Conditions are not met, the Department of Education will review the Child Care
Subsidy approval, which may result in termination of benefits.
