Preliminary Application Form for Providers

Name (First & Last)*

Address*

Postal Code*

Phone Number*

Email*

Language(s) spoken:*

Schools in your area*

Please list all persons regularly in your home:

Person 1

Name*

Date of Birth*

Relationship to You*

Hours normally in home*

Person 2

Name

Date of Birth

Relationship

Hours normally in home

Person 3

Name

Date of Birth

Relationship

Hours normally in home

Person 4

Name

Date of Birth

Relationship

Hours normally in home

Person 5

Name

Date of Birth

Relationship

Hours normally in home

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Ages of children you would like to care for:*

Availability to provide care:*

Daytime
Evenings
Weekend

Preferred hours of care:

Do you smoke?*

Yes
No

Does anyone in your home smoke?*

Yes
No

Are you vaccinated for COVID-19?*

Yes
No

Comment:

Is everyone in your household over 18 years of age vaccinated for COVID-19?*

Yes
No

Comment:

Do you have a Swimming Pool, Pond or Hot Tub?*

Yes
No

Do you have pets?*

Yes
No

Are you currently caring for children in your home?*

Yes
No

If yes, how many children and what are their ages?

Are you currently working with another home child care agency?*

Yes
No

Has anyone referred you to our service?

Are you a Registered Early Childhood Educator (RECE)?

Yes
No

Other training, education and/or experience related to child care:

Name

This field is for validation purposes and should be left unchanged.

Please list all persons regularly in your home:

Person 1

Person 2

Person 3

Person 4

Person 5

Hidden

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