Required fields are marked with asterisks (*)

Daycare Waitlist Request Form

Family Information

Name of Parent

Address

Home Telephone Number

Work Telephone Number

Email

Please check if any apply:

I already have another child on the waitlist (please write their name in the comment box at the end)

I already have another child in care at one of the Township of Russell daycare (please write their name in the comment box at the end)

I am a Township of Russell employee

Name of Child

Date of Birth (or due date)

I do not know my child's date of birth

No date of birth yet

Name of Child

Date of Birth (or due date)

I do not know my child's date of birth

No date of birth yet

Daycare Information

I need daycare service at the following location:

Mother Teresa (Russell)

St-Jean / La Croisée (Embrun)

St-Joseph (Russell)

Please note that space is not guaranteed on the desired date. We will contact you when a space is available.

For before and after school care, your child must be registered at that school in order to be eligible for care.

Comments:

Signature

Clear

Date of Signature