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 Name Last Name
Address *

Street Address

Street Address Line 2

City Province

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

English French Other

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 *

Day Month Year
Date
Hour Minutes AM/PM Option
Feedback:
Please verify that you are human *
Should be Empty:

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