Wee Watch Home Child Care
PROVIDER APPLICATION

PERSONAL
Name :
Phone :
Address :

City :
Province :
Country :
Postal Code :
Please provide your email address :
Closest main intersection :
How long have you lived there?
Years :           Months :
Previous Address if less than 5 years :

City :
Province :
Country :
Postal Code :
Social Insurance Number :
Date of Birth :
Languages Spoken :
Occupation outside home :
Marital Status :
Spouse's Name :
Spouse's Occupation :
Do you have a current driver's licence?
Yes       No      
Driver's Licence # :
Auto Insurance Company :
Liability coverage amount :

CHILDREN
Do you have children?
Yes       No      

Name :
Date of Birth :
Gender :
Name :
Date of Birth :
Gender :
Name :
Date of Birth :
Gender :
Name :
Date of Birth :
Gender :


CHILD CARE EXPERIENCE
Reason for wanting to provide day care :
List child care experience :
If you are presently caring for any day care children, give names and ages :
Other work experience :
Do you have any first aid or CPR training?
Yes       No      
Age Group Preference :
Full Time?
Yes       No      
What hours?
Part Time?
Yes       No      
What days and/or hours?
What type of activities do you plan for children in your care?
Please outline normal television watching hours and programs :

HOME ENVIRONMENT
Type of Home :
Do you rent or own?
Does your home have a basement apartment with tenants?
Yes       No      
Has your home been child-proofed?
Yes       No      
What changes will you have to make?
List the areas of your home that will be available to children :
Please list any equipment that you may have available to use (toys, crib, playpen, highchair, walker, stroller, etc.) :
Does anyone else live in your home?
Yes       No      
Who?
Do you smoke?
Yes       No      
Does your spouse smoke?
Yes       No      
Does anyone else in your home smoke?
Yes       No      
Do you have pets?
Yes       No      
What kind?
Pet's last Vaccination date :
Are you willing to have police, fire, and public health inspections?
Yes       No      
Have you (or anyone in your household) ever been charged with a criminal offence?
Yes       No      
If yes, please give details :
Are you willing to attend agency workshops?
Yes       No      
Why do you wish to join an agency?
Where did you hear about Wee Watch?

OUTSIDE
Are outdoor areas fenced?
Yes       No       N/A      
If not, will they be?
Yes       No       N/A      
Do you have a pool?
Yes       No      
Closest park(s) :
Closest library :
Closest public/separate school :
Your child's school :
Closest hospital(s) :

REFERENCES
We require 4 references - a friend, a neighbour, a close family member (not living with you), & a work-related (child care, if possible):

Reference # 1
Name :
Phone :
Email :
Address :

City :
Province/State :
Country :
Postal/Zip Code :
Relationship :
Reference # 2
Name :
Phone :
Email :
Address :

City :
Province/State :
Country :
Postal/Zip Code :
Relationship :
Reference # 3
Name :
Phone :
Email :
Address :

City :
Province/State :
Country :
Postal/Zip Code :
Relationship :
Reference # 4
Name :
Phone :
Email :
Address :

City :
Province/State :
Country :
Postal/Zip Code :
Relationship :

   


The agency will contact you to discuss your needs, answer your questions, and advise you of the registration fee.