Home Child Care Provider Application
Active Learners Licensed Home Child Care & Learning Services Ltd.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
Phone Number
Please enter a valid phone number.
Closest Main Intersection
Name of closest Public/Separate School
I own my current residence
Yes
No
Are there other adults over the age of 18 who live in your home?
Yes
No
Are there pets in the home?
Yes
No
If yes, list breed and date of last immunization
Do you or other residents of the home smoke in the home?
Yes
No
Check all that apply
I, or someone in my family, have applied to be a home child care provider and been rejected
I, or someone in my family, have applied to be a home child care provider and been rejected
I have previously / am currently providing home child care in my home
I have limitations in serving as a child care provider
I am over 18 years of age
I am legally entitled to work in Canada
I have a valid driver's license
I have vehicle insurance required to drive in Ontario including Liability coverage
I do not drive
Do you presently care for any children other than your own?
Yes
No
Do you presently care for children through another Licensed Home Child Care Agency?
Yes
No
If yes, please provide the name of the Licensed Child Care Agency and the ages of all children including your own children
Number of years in your home?
*
Please Select
less than 1
1-2
3-4
more than 5
Number of bedrooms?
*
Please Select
1
2
3
4
5
6
7 +
Number of rooms in your home?
*
Please Select
1
2
3
4
5
6
7
8
9
10+
Floors the children will have access to (check all that apply)
Main floor
2nd floor
3rd floor
My home has an outdoor play space
Please describe you outdoor area (fenced, will be fenced, fenced pool etc.)
Do you have a Pool?
Yes
No
Please list any equipment that you have available to use (crib, play pen, high chair etc.)
Are you willing to attend workshops?
Yes
No
Are you willing to have the following inspections?
Police
Fire
Public Health
Ministry of Education
The Child Care and Early Years Act, 2014 requires the following documentation to be in place prior to child care commencing.
Are you willing to provide a Vulnerable Sector Records Check for yourself and all adults over the age of 18 who reside in your home?
Yes
No
Are you willing to provide immunization records or immunization exemption documentation for medical, religious or conscience reasons for the following communicable diseases?
MMR (if born in 1970 or later)
Td/Tdap (If born in 1970 or later)
TB Assessment
Polio
Do you currently hold a valid standard first aid, including infant and child CPR?
Yes
No
Availability
Days Available
Monday
Tuesday
Wednesday
Thursday
Friday
Hours available
*
Preferred Age Range
Infants (Birth - 18 months)
Toddlers (18 - 30 months)
Preschool (30 months - 5 years)
School aged (6 - 12 years)
Date available to begin accepting children into your home
-
Month
-
Day
Year
Date
Child Care Experience/Education/Training
Education / training related to child care
*
Related child care experience
*
Are you registered with the College of Early Childhood Educators or other related regulatory body? (i.e. OCT, etc.)
Yes
No
Why do you want to become a Home Child Care Provider
*
How did you hear about Active Learners?
References
Name
First Name
Last Name
Title
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name
First Name
Last Name
Title
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name
First Name
Last Name
Title
Phone Number
Please enter a valid phone number.
Email
example@example.com
Additional Skills
List any additional skills that you would like to mention.
I understand that:
Active Learners Licensed Home Child Care & Learning Services Ltd. will contact the above individuals to provide a reference supporting my application
Written references from these individuals must be available if an interview is granted
Conditions of Application
A consent form must be signed by everyone over the age of 18 who lives in the home
I have read and understand the conditions of application
Note: Applications will be kept on file for six months. It is the responsibility of the applicant to ensure that his/her application is renewed after the six month period
Please submit a copy of your resume.
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