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APPLICATION TO HAVE CHILDREN IN YOUR HOME
As of May 2006 all Licensed Home Child Care homes are to be a smoke-free environment 24 hours a day, 7 days a week.
*
field must be filled.
Provider's Information
Last Name
*
First Name
*
Birth Date
*
(month & day = 2 digits each, year = 4 digits)
Home Address
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Closest Major Intersection
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City
*
Postal Code
*
Home telephone
*
Email Address
*
Social Insurance Number
*
Others living in the household
Complete the following fields if you've answered "Yes"
*
Yes
No
Last Name
*
First Name
*
Birth Date
*
(month & day = 2 digits each, year = 4 digits)
Relationship
*
Others living in the household
Complete the following fields if you've answered "Yes"
*
Yes
No
Last Name
*
First Name
*
Birth Date
*
(month & day = 2 digits each, year = 4 digits)
Relationship
Others living in the household
Complete the following fields if you've answered "Yes"
*
Yes
No
Last Name
*
First Name
*
Birth Date
*
(month & day = 2 digits each, year = 4 digits)
Relationship
Others living in the household
Complete the following fields if you've answered "Yes"
*
Yes
No
Last Name
*
First Name
*
Birth Date
*
(month & day = 2 digits each, year = 4 digits)
Relationship
Others living in the household
Complete the following fields if you've answered "Yes"
*
Yes
No
Last Name
*
First Name
*
Birth Date
*
(month & day = 2 digits each, year = 4 digits)
Relationship
Current Employment
Are you presently working?
*
Yes
No
If you chose "Yes", please list your current employment
Children Care
Are you presently caring for children?
*
Yes
No
Please list ages of children, if you chose "Yes"
*
List any child care/day care experience. If no experience, enter "No Experience"
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Agency Experience
Do you have any day care agency experience?
*
Yes
No
If you chose "Yes", please list the Day Care Agencies you worked with?
*
Home Information
List actual hours you are available to do child care
AM
*
PM
*
Does anyone in the home smoke?
*
Yes
No
Do you have any pets?
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Yes
No
If you chose "Yes", please your pets
*
If you chose "Yes", please choose the date of pets' last immunization
*
Select Month
January
February
March
April
May
June
July
August
September
October
November
December
Select Day
1
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Select Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
Home Environment (House/Townhouse/Other)
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Do you rent?:
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Rent
Own
List closest Public School:
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List closest Catholic School
*
Languages
What language(s) do you speak?
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Commitment
Are you willing to give this agency a
one (1) year commitment?
*
Yes
No
Applicant's Signature
Applicant's signature?
*
Date
*
Provide An Employment Reference (Excluding Relative)
Full Name
*
Telephone Number
*
Relationship
*
Provide An Employment Reference (Excluding Relative)
Full Name
*
Telephone Number
*
Relationship
*
How did you find J & F?
*
Please list
String verification
Please enter the string appearing in the image
*
Comments
Any further comments
