Provider Application Form

Provider Application Form

Welcome to BrighCare !
We’re excited that you are considering joining BrightCare’s network of home daycares. Please fill out this form to help us get to know you, your home environment, and the services you can provide.
Personal Information
Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home & Living Environment
Do you own or rent your home ?

OwnRent
Type of residence ?

ApartmentHouse
Do you have pets ?

YesNo
Child Care Experience & Training
Years of child care experience
Preferred hours of care (days and times)
Age groups you feel most comfortable caring for

Infants (0–18 months)Toddlers (18 months–3 years)Preschool (3–5 years)School-age (5+ years)
Certifications

CPRFirst AidOther
Availability & Services
When are you available to start providing care ?

MonthDayYear
Date
Typical rates and payment terms (optional)
Do you currently have openings for children ?

YesNo
References
Can you provide references from past or current families ? If yes, please provide names and contact information:
Should be Empty: