Medical Condition Assessment - Section 1 Physician or Nurse Practitioner

Sep 16, 2026

This form gathers personal and medical information under privacy and access authority for administering the Early Learning and Child Care Act. It is used to determine eligibility for the Affordable Child Care Benefit and verify that the applicant’s (or spouse’s) medical condition affects their ability to care for their children. Section 1 must be completed by a relevant physician or nurse practitioner, or authorized midwives for pregnancy to postpartum, and includes confirmation of the condition, date ranges, child care need details, and required signature, name, stamp, and date.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Section 1 Physician or Nurse Practitioner Assessment

Declaration and medical condition details

Child care required schedule and additional notes

Signature, name, stamp, and date

Section 2 Applicant Information

The personal information collected by the Ministry of Education and Child Care on this form is collected under the authority of the Freedom of Information and Protection of Privacy Act s.26(c)forthe purpose of administering the Early Learning and Child Care Act.If ou have any questions about the collection,use or disclosure of this information,please call the ChildCare Service Centre at1-888-338-6622 or inquire in writing to the address at the end of this form. Medical Condition:The purpose of this form is to establish eligibility for the Affordable Child Care Benefit and confirmthe applicant's (or spouse's)medical condition interferes with their ability to care for their children. # Section 1 Physician or Nurse Practitioner Assessment This section must be completed by a physician or nurse practitioner in a medical field relevant to the patient's medicalcondition.Midwives may complete this section and authorize this form when the condition is 'pregnancy to postpartum' related.This form is not to be used for 24 Hour Care,Respite Care,Homemakers,Child or Family Support Workers. | I confirm that
(Name of the person with medical condion)
has a medical condition that interferes with their ability to care for their children. | | | | --- | --- | --- | | The medical condition is:C Permanent Start Date:
(yyy-mmm-dd)
or
Expected End Date:
Temporary Start Date:
or
□Unknown
(yyy-mmm-dd)
(yyy-mmm-dd) | | | | Child care is required for all children or
list names of children requiring care: | | | | Specify the days and times child care is required due to the medical condition
□TUE □WED □THU □FRI □SAT SUN
□MON
Days/week:
Time of day child care is required:From:______To:______
If this person has school aged children,indicate days and times care is required when school is not in session:
□TUE □WED □THU □FRI □SAT □SUN
□MON
Days/week:
Time of day child care is required: From:_____To:_____ | | | | Additional Information | | | | Physician's or Nurse Practitioner's Signature | Physician's or Nurse Practitioner's Name | Date Signed (yyy-mmm-dd) | | Physician's or Nurse Practitioner's Stamp with Contact Information | | | Please return to the applicant to complete Section 2 and submit to the Child Care Service Centre. # Section 2 Applicant Information | Legal Name(Please Print) | Social Insurance Number | Phone (999-999-9999) | | --- | --- | --- | | | | | Once completed,please fax or mail to the Child Care Service Centre Mailing Address Child Care Service Centre PO Box9953 Stn Prov Govt Victoria BC V8W 9R3 # AFFORDABLE CHILD CARE BENEFIT DOES NOT PAY FOR THE COMPLETION OF FORMS

FAQs

Who is allowed to complete Section 1 of this form?

Section 1 must be completed by a physician or a nurse practitioner in a relevant medical field. Midwives may complete it and authorize the form when the condition is pregnancy to postpartum related.

What eligibility purpose does this medical condition form serve?

The form establishes eligibility for the Affordable Child Care Benefit and confirms that the applicant’s (or spouse’s) medical condition interferes with their ability to care for their children.

What medical condition dates must be provided in Section 1?

Section 1 requires either a permanent start date or an expected end date (for a permanent/ongoing condition), or temporary start dates, with an option for unknown when applicable.

Sep 16, 2026

Uploaded by Nguyễn Văn Học