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Infant and Child Development Services Referral

* = Required

Parent / Caregiver Information

Healthcare Provider Information

Child Information

* Gender

Family Information

* Family involved with Family and Children's Services Niagara

* Child is in foster/kinship care

Additional Information

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email or call 905-980-6000 ext. 3779.

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