Providers Application

Family Information

Names and Birthdates of children resident with the applicant

Child´s Name

Date of birth

Gender

Female Male

Child´s Name

Date of birth

Gender

Female Male

Child´s Name

Date of birth

Gender

Female Male

Names and Relationship of other residents in the applicant´s home, who are over 18 years of age.

Name

Relationship

Name

Relationship

Name

Relationship

General Information

Why are you interested in becoming a dayhome provider?

Does your whole family support in this application to be came a Day Home Provider?

Yes No

Are you willing to provide care for children with Special Needs?

Yes No

Are you willing to provide care during extended hours (i.e. Evenings, weekends, and holidays)?

Yes No

If yes. What hours would you be available?

What ages of children would you prefer to care for and how many?

Where in your home will you be setting up your playspace? (must have a window)

What form of child guidance do you use?

List 5 examples of field trips you would take with the children and how you will get there:

Are you planning to use your vehicle to transport children?

Yes No

What play/child care equipment do you have?

What hours and days would you be willing to take care children?

Monday

Hours at day

Tuestday

Hours at day

Wednesday

Hours at day

Thursday

Hours at day

Friday

Hours at day

Saturday

Hours at day

Sunday

Hours at day

When would you be available to start caring for children?

Education - Training

Have you completed any classes in Early Childhood Education, psychology, nutrition, crafts, etc.?

Yes No

If yes, please give more detalles below:

Are you interested in increasing your knowledge and understanding of young children?

Yes No

If yes. By what means?

Do you have firts Aid Certificated?

Yes No

If yes, What is the expiry date?

Experience

What was your last job?

Do you have any special abilities or interests that would help you to relate to the children?

Have you been a Day Home Provider?

Yes No

IIf yes, Which Agency were you with?

Do you normaly plan ahead in daily activities...etc.?

Yes No

Health Information

Have you experienced any of the following in the past five years?, Serious Illness, Injury, health problems, professional assitance with emotional, psychological, behavioral or psichiatric problems?

Yes No

If yes, please explain below:

Does anyone in your household smoke?

Yes No

Do you have pets in your home? Please specify...

Yes No

Is your child's immunization up-to date?

Yes No

If not, Please note: If an outbreak of vaccine preventable illness occurs, and your child has not received medical immunisation, your child will not be able to attend the centre during this time. If Yes, please provide the details by: Attaching a copy of the immunisation record from the Child Health Record Book

Is there is anything else that the agency should know about your healt?

How did you hear about us?

Little Children Day Homes must require that family day home provider applicants are at least 18 years old and that they provide the following documents prior to approval and providing child care:

A completed criminal record check, including vulnerable sector search, Child Intervention Check for the applicant and anyone who is over 18 years of age or older, and who either resides with the provider in the proposed family day home or who may be in the provider’s home on a regular basis during the provider’s regular operating hours.
A statement signed by the applicant disclosing any prior criminal involvement of any person younger than 18 years old who resides with the provider in the proposed family day home.
Three satisfactory personal references from non-relatives that corroborate the provider’s.
Suitability for working with children.
A physician’s note that states the applicant is mentally and physically able to care for children.
Home safety check.
First Aid Certification.
Application Form.
Inssurance.