Child Care Provider Information Form

Child Care Provider Information Form

Thank you for your interest in providing child care services. Please complete the form below to provide us with necessary information about your child care services.
Provider's Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City Province

Zip CodeCountry
Do you owe your house?

YesNo
What type of housing do you have? (apartment, house etc)
How many years of experience do you have in child care?
What age group of children do you specialize in caring for?

Infants (0-1 year)Toddlers (1-3 years)Preschoolers (3-5 years)School-age children (5-12 years)
What is your preferred child care hours?

7am-6pmOvernightWeekendCasual-Back up replacement
Are you CPR and First Aid certified?

YesNo
Do you have any specialized child care training or certifications?
Do you have any pets in your home?

YesNo
If yes, please provide details about your pets.
What is your availability for child care services?
Please provide details about your child care rates and payment terms.
Do you have references from previous child care clients?

YesNo
If yes, please provide contact details for your references.
Should be Empty: