Emergency School Age Child Care Application Form Share: Share on Facebook Share on Twitter Share on Pinterest Email Complete Form Please select which program you would like to attend: Napanee Amherstview Picton Massassagna-Rednersville Anticipated Start Date (DD/MM) Section 1: Applicant Information Applicant 1: Applicant's Relationship to the Child(ren) Parent Guardian Other Name Date of Birth (DD/MM/YYYY) Address City/Town Postal Code Phone Number Email Marital Status Applicant 2: Applicant's Relationship to the child(ren) Parent Guardian Other Name Date of Birth (DD/MM/YYYY) Section 2: Employment and Eligibility Information Applicant 1 Employer Name Employer Contact Phone Number Job Position/Title Employer Address Anticipated Work Days Monday Tuesday Wednesday Thursday Friday Saturday Sunday Anticipated Work Hours (Start - End) Does Applicant 1 have the option to work from home? Yes No Applicant 2 (if applicable) Employer Name Employer Contact Phone Number Job Position/Title Employer Address Anticipated Work Days Monday Tuesday Wednesday Thursday Friday Saturday Sunday Anticipated Work Hours (Start - End) Does Applicant 2 have the option to work from home? Yes No Child Information Child 1 Full Name Date of Birth (DD/MM/YYYY) Child 2 Full Name (if applicable) Date of Birth (DD/MM/YYYY) Child 3 Full Name (if applicable) Date of Birth (DD/MM/YYYY) Child 4 Full Name (if applicable) Date of Birth (DD/MM/YYYY) Evidence of employment is required for each applicant. A letter from your employer, paystub or employee badge is acceptable. This is required for all applicants and will allow us to process your application more quickly if it is attached to the application. A photo taken with your phone/camera is sufficient as long as it is legible, so please verify this before uploading the image. Click "Choose Files" to upload Employer letters or pay stubs for each applicant. Maximum 4 files.8 MB limit.Allowed types: gif jpg jpeg png pdf doc docx. If you are unable to upload this information other arrangements can be made when you are contacted by our office. If you have any questions please contact PELASS Children’s Services Department at 613-354-0957 x 2402 or email childcare@lennox-addington.on.ca. I confirm understanding of the conditions of PELASS’s emergency child care services as identified in the Consent Form (click here to view). Further, I give consent for PELASS to collect information regarding the attendance and screening results for all children attending emergency child care services. Click 'Yes' to provide consent. Yes, I agree. Leave this field blank
