Required fields are marked with asterisks (*)

County of Renfrew Licensed Home Child Care Provider Application Form

General Provider Information:

Full Name

Name of Home Daycare

Telephone (Home)

Telephone (Cell)

Full Address

What is your status in Canada?

Canadian Citizen

Permanent Resident

Other

Languages spoken at home:

English

French

Other

Area Schools (Please list)

Email:

Availabilty to provide care:

Hours available to provide care:

Days available:

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred start date:

Ages of children you are comfortable working with (Check all that apply)*:

Under 1

1-2

2-3

3-4

4-6

*All child placements would be required to abide by Ministry Of Education regulations regarding ratio as outlined in the CCEYA.

Program Information

Welcoming Environment - How will you make your home feel warm and welcoming so children and families feel comfortable and included?

Working with Families – How will you work together with parents/guardians to support each child’s growth and needs?

Health and Safety – How will you keep children healthy, safe, and well cared for while they are in your home?

Learning Through Play – How will you provide a variety of materials, activities, and experiences that encourage curiosity, exploration, and hands-on learning both indoors and outdoors?

Caregiver Information

Ongoing Learning for You – How will you keep learning new ways to give children the best care possible? What topics would you like to learn more about to grow your abilities, knowledge, and understanding in being a Child Care Provider?

Social/Emotional Support – How will you support children in times of heightened emotions and/or struggling to self-regulate?

Children (Living in your home)

Full Name(s) & Date of birth(s)

Other Occupants (Living in your home)

Full Name(s) & Relationship to applicant

Qualifications

Please explain your education and or experience related to child care:

Expiration date

Expiration Date

ENVIRONMENTAL INFORMATION (Select Yes or No) These are not requirements to open a home, just items that may require further discussion

Working with children involves certain physical activities. You will need to complete an attestation confirming that you are able to meet these requirements. Examples include but are not limited to bending, lifting, standing, twisting, pushing, and doing repetitive movements.

Do you have any questions or feedback to offer?

Reference Permission

I grant permission to the County of Renfrew Licensed Home Visitor or designate to contact any and all references as listed below. (Please initial)

Please provide two professional references and one personal reference. Please list full names and phone numbers.

Professional Reference Name and Phone Number:

Personal Reference Name and Phone Number:

I understand that the questions asked by County of Renfrew Licensed Home Child Care staff members (Licensed Home Visitors) will be pertinent to the application I have filled out to be a Child Care Provider for the agency. The answers given by my references will be for agency use only and will be kept confidential in a secure location in the office of County of Renfrew Licensed Home Child Care. When this file becomes obsolete for agency use, it will be destroyed as per the Agency’s Record Retention Policy.

Signature of applicant

Clear