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Childcare Claim Form ProviderConnect 2015-2023
Claimed. There is no need to attach receipts if this form is completed in full including authorized signatures of the Employee/Parent or Guardian and a facility official. CHILDCARE PROVIDER INFORMATION Childcare Provider No. Not for Profit For Profit Childcare Facility Name Address Telephone Number Province City PLAN MEMBER INFORMATION Employee Name Last Child s Name Postal Code Employer Child s Green Shield ID No. First Child s Date of Birth / Y Do you have any other Childcare Coverage Yes If...
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