Become a Licensed Home Child Care Provider

APPLICATION TO PROVIDE HOME CHILD CARE (HCC)

Required fields.

Application Home Child Care

A. CAREGIVER PERSONAL INFORMATION
Name*
First Last
Email*

Your Preferred Email
Phone*
Address*
Street Address Address Line 2 City Province Postal Code
Are you 18 Years of age or older?*
- Yes
- No
Are there any adult(s) (18 years of age and over) living in your home?*
- Yes
- No
Name
First Last
Relationship
Name
First Last
Relationship
Name
First Last
Relationship
Are there any children (under 18 years of age) living in your home?
- Yes
- No
Name
First Last
Date
MM
DD
YYYY
Name
First Last
Date
MM
DD
YYYY
Name
First Last
Date
MM
DD
YYYY
B. AGE CATEGORY AND NUMBER OF CHILDREN PREFERRED
Please indicate the age category and number of children you would prefer.
- Infants (up to 2 years)
- Preschoolers (2 years and up)
Please enter a value between 0 and 2.
(Maximum: 2 children under age of 2)
Please enter a value between 0 and 3.
(Maximum: 3 children under age of 3)
Indicate schools and addresses within bussing and walking distance of your home.
School
Address
School
Address
School
Address
C. *PLEASE DESCRIBE YOUR EXPERIENCE WITH CHILDREN
DESCRIBE YOUR EXPERIENCE WITH CHILDREN*
D. YOUR PERSPECTIVE ON CARING FOR CHILDREN
As a caregiver what do you think a child needs from you each day?*
How would you go about meeting these needs?*
How do you view the relationship between you and the Home Visitor of Family Space Quinte Inc.?*
Describe your reasons for wanting to become a caregiver registered with our licensed home child care program?*
E. EMERGENCY REPLACEMENT
During times of an emergency or personal appointments, an alternative person, known to you, must be available to come to your home to care for the children. The adult you name should, in your opinion, be capable of providing appropriate care. Please identify the alternate caregiver.
Name of Alternative Person
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Tell us how you heard about Family Space*
F. INFORMATION
*
- I certify that all the information provided in this application is accurate and complete to the best of my knowledge, and I understand that intentionally providing false information could result in refusal of my application or termination of my Licensed Home Child Care contract with Family Space Quinte Inc.
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Become a Licensed Home Child Care Provider

APPLICATION TO PROVIDE HOME CHILD CARE (HCC)

Application Home Child Care

A. CAREGIVER PERSONAL INFORMATION

B. AGE CATEGORY AND NUMBER OF CHILDREN PREFERRED

C. *PLEASE DESCRIBE YOUR EXPERIENCE WITH CHILDREN

D. YOUR PERSPECTIVE ON CARING FOR CHILDREN

E. EMERGENCY REPLACEMENT

F. INFORMATION

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