Home Child Care Provider Application

Licensed Home Child Care Provider Application
Thank you for your interest in becoming a home child care provider. For more information on the home child care program, please contact LHCC@timiskamingchildcare.ca
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*
E-mail*
example@example.com
Languages Spoken*

EnglishFrenchOther

Experience
Why would you like to become a Licensed Home Child Care Provider?
What are your expectations for joining our agency?
Do you have any previous experience or training with children? Please provide details.
How did you hear about our home child care program?

References

Please provide two references related to your child care experience.

	Reference 1	Reference 2
Name
Relationship
Email
Phone Number

I give consent for Centre pour enfants Timiskaming Child Care to contact the references I have provided.

Yes

Notes
Please enter any comments, notes, questions or additional information you would like to provide.

Confirmation
I confirm that all information provided in this application is true and accurate.*

Yes
Signature*

Clear
Current Date and Time*

DayMonthYear
Date
Hour MinutesAM/PM Option
Feedback:
Please verify that you are human*
Should be Empty: