CHILD CARE RECEIPT

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CHILD CARE RECEIPT
FALL / WINTER



 The personal information on this form is collected under the authority of the Royal Charter of 1841, as amended. The information
 collected will be used by the Office of the University Registrar to process your request as identified on this form. For more
 information, please contact the Office of the University Registrar, Student Awards, Queen's University, Gordon Hall. Telephone:
 (613) 533-2216.


 Instructions:
 Please complete this form if you have claimed childcare expenses on your General Bursary Application. Your childcare
 provider should indicate the actual childcare costs you have incurred for the first eight weeks of your study period. Also,
 indicate expected childcare costs for the remaining weeks of your study period.

                                                       c
 If more than one person provides childcare, each child- are provider must fill out a separate receipt. Incomplete receipts
 will not be accepted.

 Student Information (to be completed by student)
 Last Name (Student)                                   First Name (Student)                                   Student #




 Child-Care Receipt (to be completed by child-care provider)

                                                              Amount received per child:                   Amount expected per child:
                                                          (First eight weeks of current Study Period)   (Remaining weeks of current study period)

Name of Child(ren)                                                    September – October                     From November to



                                                                  $                                            $


                                                                  $                                            $


                                                                  $                                            $


                                                                  $                                            $

                                                                  $                                            $




Name of Child Care Provider

Address

City                                       Prov            Postal Code



I agree that the information provided on this form is complete and true.


Childcare provider's Signature                                                           Date (dd-mm-yyyy)




Updated November 16, 2006 CP