Apply Today Provider Application FormOffice Use OnlyDate Application Form Received: Provider Start Date: MM slash DD slash YYYY Home Visitor: Maverine Guerreiro Providers InformationFirst and last name:(Required) Preferred Name:(Required) Full Home Address (Include Postal Code)(Required) Street Address City Province ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Language(s) spoken: Major Intersection: Email Address:(Required) Phone Number:(Required)Are you over the age of 19 years and legally eligible to work in Canada?(Required) How did you hear about Childspec LHDCS?(Required) Do you or anyone in your household have a criminal record?(Required) Do you have a valid Vulnerable Sector Check?(Required) Date:(Required) MM slash DD slash YYYY O. Reg. 137/15 ‣ Before entering into an agreement with a home child care provider the agency shall obtain a vulnerable sector check form: * The home child care provider Every person who is a resident of the premises and every person who is regularly at the premises and ‣ Is 19 years of age or older, ‣ Except if more than 6 months has passed since the day the vulnerable sector check was performed. ‣ The agency shall obtain a new VSC on or before every fifth anniversary after the most recent VSC and; ‣ A new offence declaration, in every calendar year except a year in which a VSC is obtained, within 15 days of the anniversary date of the most recent OD or VSC. ‣ Where an individual turned 18 years of age, they are required to submit an offence declaration. Persons over the age of 19 years:List persons residing at your home:First & Last Name(Required) Relationship Home during childcare hours? First & Last Name(Required) Relationship Home during childcare hours? First & Last Name(Required) Relationship Home during childcare hours? First & Last Name(Required) Relationship Home during childcare hours? Persons 18 years old:First & Last Name(Required) Relationship Date of Birth Persons under the age of 18 years:First & Last Name(Required) Relationship Date of Birth Immunization Records: Childcare providers and individuals regularly in the home over the age of 18 years that are not in public school are required to submit to the agency up to date MMR & TDP vaccines. Childcare providers and individuals regularly in the home over the age of 18 years are also required to have a TB assessment that is dated within 6 months of the providers start date. Medical forms and assessments are to be signed by a medical professional. Please check with the agency for the Medical Forms. reschool Children in the home: The provider is required to submit to the agency a copy of Immunization records for preschool children residing in the home. Ferrets, cats & dogs required rabies certificate. Are there pets in the home? Type: List child care work experience or other credentials: Are you currently contracting with other licensed home child care agencies? Please list training programs you have completed to enhance your childcare program Smoke Free Act Ontario: https://www.ontario.ca/page/where-you-cant-smoke-or-vape-ontario - section-3 Name(Required) Relationship Best time to call(Required) Contact Number(Required) References: Please list 3 persons that have observed you working with children. Please notify your references that the agency will call and request they complete a short questionnaire. Locations providing home child care must be smoke-free and vape-free at all times, even when children are not present. This includes outdoor spaces where children play. (Includes- e-cigarettes & Marijuana) Is your home a smoke/vape free environment? Valid certification in Standard First Aid and CPR Level “C” (2 days program) is required to be submitted to the agency prior to the placement of children: Do you have valid First Aid and CPR - L “C” certification? expiration date: MM slash DD slash YYYY I have read the Provider Handbook and understand the responsibilities of a home childcare provider. I agree to abide by the policies as stated in the Provider Handbook to the best of my ability. I have read the Provider Handbook and understand the responsibilities of a home childcare provider. I agree to abide by the policies as stated in the Provider Handbook to the best of my ability. I have read the Provider Handbook and understand the responsibilities of a home childcare provider. I agree to abide by the policies as stated in the Provider Handbook to the best of my ability. I have read the How Does Learning Happen? and agree to abide by the document to the best of my ability. https://files.ontario.ca/edu-how-does-learning-happen-en-2021-03-23.pdf I have read the Provider Handbook and understand the responsibilities of a home childcare provider. I agree to abide by the policies as stated in the Provider Handbook to the best of my ability. I have reviewed the Ontario Dietitians in Public Health (ODPH) Practical guide for menu planning. https://www.odph.ca/child-care-resources I understand I am an independent contractor operating a child care business in my home and not an employee of the agency. I understand I am an independent contractor operating a child care business in my home and not an employee of the agency. I agree to notify my home/auto insurance company of my business operations and obtain liability insurance as required. I understand I am an independent contractor operating a child care business in my home and not an employee of the agency. General InformationHours of Operation (Include evenings or weekends) Type of home (do you own or rent)? Do you have tenants in your home? Name of local schools Will you be available to walk children to and from school? Are you currently caring for children? Please list how many and ages. Which age group would you like to work with? Do you agree to attend a minimum of 8 hours of training to support quality child care per year? Do you have privately placed children in your care? Please list how many and ages. When will you be available to start working with Childspec LHDCS? What do you like about being a home child care provider? SafetyIs there a working smoke detector on every level of your home? Is there a working carbon monoxide detector outside sleeping areas? Do you have a working fire extinguisher (ex:10 BC) Do you have a first aid kit with manual? Are there any guns or other weapons in your home? Do you have a pool on your property? Is outdoor play area fenced? EnvironmentDo you have child size furniture ex: table and chairs Do you have toys and other activities available to children indoors on open shelves? Which areas of your home will be designated specifically for child care? Do you have outdoor play materials? Do you agree to ensure children play outdoors for up to 2 hours daily weather permitting? Are you willing to make changes to your home to help meet licensing requirements and to enhance the quality of care? How might your household members react to changes you may be making to accommodate your child care business? NutritionAre menus planned that follow Health Canada Guidelines? Please give an example of a lunch. ttps://www.odph.ca/child-care-resources Do you agree to complete the Nutrition Training Package provided you the agency once every 2 years? I certify that the information I have supplied on this Provider Application Form is both complete and correct to the best of my knowledge. I agree that the agency may further investigate this information and contact the references listed above to inquire about my work history with children. I understand that my personal information will be shared with the Ministry of Education, Health Department, Region of Peel and clients upon request for the purpose of obtaining childcare services. Date Application Form completed by Provider: Signature of Provider:(Required)Ending Date of Contract with agency: MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
