Provider Registration

REGISTRATION - POTENTIAL PROVIDER
If you are interested in a partnership with Andrew Fleck Home Child Care, we would love to hear from you! Please fill out the questions below and contact us to register for an information session.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Main contact number*
Other number
E-mail*
Language spoken in your home.*

EnglishFrenchSpanishArabicOther

Person(s) living in your home (18 years and older)

	Name	Relationship to Provider
1.
2.
3.
4.

Person(s) living in your home under 18 years of age

	Name	Birthdate mm/dd/yyyy	Relationship to Provider
1.
2.
3.
4.

	Daytime	Evenings	Weekends	Overnight
Select all that apply

Please provide as much detail as possible when answering the following questions:
17. Please describe why you are interested in becoming a home child care provider:*

0/500
18. What do you think are important qualities of a home child care provider?*

0/500
19. Describe play activities you would offer:
An infant (0-12 months)*

0/500
A toddler (12 months - 30 months)*

0/500
A preschooler (30 months - 48 months)*

0/500
A school age child (48 months and up)*

0/500
20. How do you manage children's challenging behaviours?*

0/500
21. Will your TV be on during child care hours?*

YesNo
How long will the TV be on?*
Indicate length of time
22. Do you plan to take the children outside daily?*

YesNo
How long will you be spending time outside?*
Indicate length of time

References & Statement of Understanding

Please provide us with three references (non-relatives) that we can contact. For example a neighbour, former employer or previous child care client, may be used.*

	Name	Daytime phone #	Relationship
1.
2.
3.

We appreciate your interest in partnering with us to provide home child care with our licensed program. Andrew Fleck Children’s Services strives to establish professional partnerships with self-employed individuals who offer development opportunities for children in a stimulating and inclusive early learning and care environment.

The home screening process is lengthy and thorough and does not guarantee that we will place children in your home. In order for you to become a partner of our Home Child Care Program, your home and operating practices must meet all standards & regulations of the Child Care and Early Years Act and Andrew Fleck Children's Services. This includes, but is not limited to, the following:

-A Vulnerable Sector Check for you, your family members and anyone regularly in your home over the age of 18 (please check with your local police department for more information).

-A health assessment from your physician for you, your family members, and anyone regularly in your home; this includes up-to-date immunization records and (if applicable) results of TB testing.

-Certification in Standard First Aid and CPR-C.

-A safe environment for children, as determined by the successful completion of a home safety check.

Please note: you are not required to proceed with any of the above-mentioned items or paperwork at this time. This information will only be required if we proceed with the home opening process. If our agency offers a First Aid/CPR training and you choose to attend but then decide not to proceed with home opening, you may be responsible to reimburse the agency for the cost of the course. If you choose to seek certification outside of agency courses, please keep your receipt as we may be able to offer reimbursement if there are funding opportunities.

If you require any assistance or additional information throughout this process, we welcome you to contact us at: (613) 736-1913 (ext. 238) or hcc@afchildrensservices.ca
I certify that I have completed this registration on my own.*

Clear
Please use your cursor or finger to sign.
Should be Empty:

	Date of birth (mm/dd/yy)	School/ grade (if applicable)	Future enrolled date if not currently enrolled	Notes
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2.
3.
4.
5.

	Place of employment	Position	Start date - end date (mm/yy -mm/yy)	Age group(s)
1.
2.
3.

	Volunteer location	Position	Start date - end date (mm/yy-mm/yy)
1.
2.

	Name of school	Distance from house
1.
2.
3.

REGISTRATION - POTENTIAL PROVIDER