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Application for Licensed Home Child Care

Child Care Program

Today's date:

Start date for child care:

Have you applied for child care with our agency in the past?

Yes

APPLICANT 1

First and Last Name:

Previous Name (if applicable):

Date of Birth:

Person with legal custody (if separated or divorced):

Marital Status:

Single

Married

Common Law

Address:

Apartment Number:

Postal Code:

City/Town:

Municipality:

Telephone Number:

Cell phone number:

Email address:

Preferred language of communication:

Are we able to leave a detailed message?

Yes

APPLICANT 2

Spouse, common-law partner of more than three years, or parent of the child(ren)

Name:

Date of Birth:

Phone number:

Are we able to leave a detailed message?

Yes

CHILDREN REQUIRING CARE

First and Last Name:

Date of Birth:

School Name:

Grade:

First and Last Name:

Date of Birth:

School Name:

Grade:

First and Last Name:

Date of Birth:

School Name:

Grade:

First and Last Name:

Date of Birth:

School Name:

Grade:

Additional information (health concerns, for example):

Notice with respect to the collection of personal information
Municipal Freedom of Information and Protection of Privacy Act (MFIPPA)
Freedom of Information and Protection of Privacy Act (FIPPA)
Personal Information Protection and Electronic Document Act (PIPEDA)

This information is collected under the legal authority of the Child Care and Early Years Act, 2014, for the purpose of determining or verifying a person’s eligibility to participate in a child care or early years program or service or to receive financial assistance under this Act. Section 71 (1) 2.

You will be contacted within 10 business days of receipt of your application in order to schedule an interview. Please notify Child Care Services of any changes to your contact information.

Form Builder

Application for Licensed Home Child Care