Complete a request

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General information

Please fill out this initial contact form to allow us to evaluate your request. We will contact you to complete your file if your request is accepted. We will communicate with you within 48 business hours.

Fields marked with an asterisk (*) are required

N.B. You can choose several services at the same time in the same service request

As spots are limited, in the event of high demand, we may need to temporarily suspend once again the ability to submit new requests for the home service, in order to ensure a balanced management of the waiting list and to adequately meet demand..

N.B Registrations FOR 5-12 SUMMER DAY CAMP must be completed directly through the City of Salaberry-de-Valleyfield, under the “Programme d'intégration” section.

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Opening date of the request

Select the service(s) you wish to obtain*

In Home Respite Care Service - located in MRC V-S, B-S, HSL
Maison Zéphyr - located in Vaudreuil-Dorion
Maison Jean-Reid - located in Salaberry-de-Valleyfield
Shared-Respite - located in Salaberry-de-Valleyfield
March Break Day Camp - 13-21 years old - located in Salaberry-de-Valleyfield
A place for 0-5 and accompaniment for all

Primary parent

Name of the parent responsible for the request*

Father
Mother
Other

Preferred language*

French
English
Other

Other - Specify language

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Contact information

Home address*

City*

Postal code*

Telephone*

Email*

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Secondary parent

Family name / Given name of secondary parent

Father
Mother

Inscription EN

General information

Primary parent

Contact information

Secondary parent

Beneficiary of the service

Status level