Wee Watch Home Child Care
PROVIDER APPLICATION
PERSONAL
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Select one...
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St. Kitts and Nevis
St. Lucia
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Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Togo
Tortola
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Other
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 :
Select one...
Other
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Country :
Select one...
Canada
United States
United Kingdom
Japan
Australia
France
Hong Kong
Germany
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Barbuda
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Botswana
Brazil
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Colombia
Congo-Brazzaville
Congo-Kinshasa
Cook Islands
Costa Rica
Croatia
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea Bissau
Guinea
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Jordan
Kazakhstan
Kenya
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar/Burma
Namibia
Nepal
Netherlands Antilles
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saba
Saipan
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Somalia
South Africa
South Korea
Spain
Sri Lanka
St. Barthelemy
St. Croix
St. Eustatius
St. Kitts and Nevis
St. Lucia
St. Maarten/St. Martin
St. Thomas
St. Vincent
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Togo
Tortola
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Other
Postal Code :
Social Insurance Number :
Date of Birth :
Jan
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2046
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2048
2049
2050
Languages Spoken :
Occupation outside home :
Marital Status :
Select one...
Single
Married
Divorced
Separated
Common-Law
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 :
Jan
Feb
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May
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2050
Gender :
Name :
Date of Birth :
Jan
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2048
2049
2050
Gender :
Name :
Date of Birth :
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
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1977
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1981
1982
1983
1984
1985
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1987
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1989
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1991
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2046
2047
2048
2049
2050
Gender :
Name :
Date of Birth :
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
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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 :
Select one...
House
Apt.
Townhome
Do you rent or own?
Select one...
Rent
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 :
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
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1911
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1977
1978
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1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
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2015
2016
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2035
2036
2037
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2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
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 :
Select one...
Other
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Country :
Select one...
Canada
United States
United Kingdom
Japan
Australia
France
Hong Kong
Germany
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Barbuda
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Botswana
Brazil
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Colombia
Congo-Brazzaville
Congo-Kinshasa
Cook Islands
Costa Rica
Croatia
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea Bissau
Guinea
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Jordan
Kazakhstan
Kenya
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar/Burma
Namibia
Nepal
Netherlands Antilles
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saba
Saipan
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Somalia
South Africa
South Korea
Spain
Sri Lanka
St. Barthelemy
St. Croix
St. Eustatius
St. Kitts and Nevis
St. Lucia
St. Maarten/St. Martin
St. Thomas
St. Vincent
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Togo
Tortola
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Other
Postal/Zip Code :
Relationship :
Reference # 2
Name :
Phone :
Email :
Address :
City :
Province/State :
Select one...
Other
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Northwest Territories
Nunavut
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Alberta
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Reference # 4
Name :
Phone :
Email :
Address :
City :
Province/State :
Select one...
Other
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Country :
Select one...
Canada
United States
United Kingdom
Japan
Australia
France
Hong Kong
Germany
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Barbuda
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Botswana
Brazil
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Colombia
Congo-Brazzaville
Congo-Kinshasa
Cook Islands
Costa Rica
Croatia
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea Bissau
Guinea
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Jordan
Kazakhstan
Kenya
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar/Burma
Namibia
Nepal
Netherlands Antilles
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saba
Saipan
San Marino
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Somalia
South Africa
South Korea
Spain
Sri Lanka
St. Barthelemy
St. Croix
St. Eustatius
St. Kitts and Nevis
St. Lucia
St. Maarten/St. Martin
St. Thomas
St. Vincent
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Togo
Tortola
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Other
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The agency will contact you to discuss your needs, answer your questions, and advise you of the registration fee.