**Provider Application Form**

**PROVIDER INFORMATION**

**First Name:** ______________________
**Last Name:** ______________________
**Gender:** □ Male □ Female □ Other
**Address:** ______________________
**Date of Birth:** ______________________
**Unit:** ______________________
**Languages spoken:** ______________________
**City:** ______________________
**Email Address:** ______________________
**Postal Code:** ______________________
**Phone:** ______________________
**Province:** □ Choose from dropdown

**Cell:** ______________________
**Closest main intersection:** ______________________
**Years at this address:** ______________________

**CHILD CARE EXPERIENCE**

**Reasons for wanting to Provide home childcare:** ______________________
______________________

**Describe any previous childcare experience you have:** ______________________
______________________

**Are you currently caring for children in your home?:** □ Yes □ No
**If yes, how many and what ages?:** ______________________

**List other work experience:** ______________________
______________________

**Are you fully vaccinated for COVID-19?:** □ Yes □ No □ Exemption □ Partial
**Comment:** ______________________

**Are you a Registered Early Childhood Educator (RECE)?:** □ Yes □ No
**Registration:** ______________________

**Do you have Standard First Aid certificate and CPR Level C?:** □ Yes □ No
**Expiry Date:** ______________________

**How did you hear about [Business Name]?**
______________________

**SCHEDULE AND PREFERENCES**

**What hours do you want to work?:** □ Full Time □ Part Time
**What hours would you work?:** □ Days □ Evenings □ Weekends □ Overnights
**What ages of children would you prefer to care for?:** ______________________

**HOUSEHOLD INFORMATION**

**Type of Home:** □ House □ Apartment □ Townhouse
**Ownership:** □ Own □ Rent
**If you rent, have you notified your Landlord about operating home childcare?:** □ Yes □ No
**Are outdoor areas fenced?:** □ Yes □ No □ N/A
**Do you have a pool?:** □ Yes □ No
**Do you have pets?:** □ Yes □ No
**Types of Pets:** ______________________

**Does your home have an apartment/unit with tenants?:** □ Yes □ No
**If Yes, does the apartment/unit have a locked door between units or a separate entrance?:** □ Yes □ No

**Closest school(s):** ______________________
**Would you be willing to walk to and from school with children in care?:** □ Yes □ No

**List all person(s) above 13 years old living in the home**
**First Name:** ______________________ **Last Name:** ______________________ **Relation to Provider:** ______________________

**Is everyone in your household over 18 fully vaccinated for COVID-19?:** □ Yes □ No
**Comment:** ______________________

**Do you or anyone living in the home smoke (tobacco/marijuana)?:** □ Yes □ No
**Do you or anyone in your household have a criminal record?:** □ Yes □ No
**Criminal Records Comment:** ______________________

**List all person(s) under 13 years old living in the home**
**First Name:** ______________________ **Last Name:** ______________________ **Gender:** □ Male □ Female □ Other
**Date of Birth:** ______________________

**REFERENCES**

**Reference 1**
**Name:** ______________________ **Phone #:** ______________________ **Address:** ______________________ **Relationship:** ______________________ **Email:** ______________________

**Reference 2**
**Name:** ______________________ **Phone #:** ______________________ **Address:** ______________________ **Relationship:** ______________________ **Email:** ______________________

**Reference 3**
**Name:** ______________________ **Phone #:** ______________________ **Address:** ______________________ **Relationship:** ______________________ **Email:** ______________________

**Reference 4**
**Name:** ______________________ **Phone #:** ______________________ **Address:** ______________________ **Relationship:** ______________________ **Email:** ______________________

**SIGNATURE**

I certify that the information I have supplied on this application is correct, and agree that [Business Name] may verify this information and contact the reference list above in connection with my proposed relationship with the agency.

**Signature:** ______________________ **Date:** ______________________