Child Care Provider Registration Form
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2Provider Database ID
Child Care Information Exchange
Registry of Home-Based Child Care
Child Care Provider Registration Form
Care Provider’s Name:___________________________________________________
Address:_______________________________________________________________
City: ________________________________Postal Code:____________________
Telephone:_______________________________
Email address:__________________________________________________________
Closest Major Intersection:_______________________________________________
Schools in area:_________________________________________________________
_______________________________________________________________________
Provides escort to school: Yes ___ No ____ other___________________________
Do you have young children of your own? _________ Ages:____________________
Do you provide care through a licensed agency? _______
Name of agency:
________________________________________________________________________
General Location
Circle one
City
North
South
East
West
Otonabee
Central
County
Asphodel-Norwood
Douro-Dummer
Galway-Cavendish-Harvey
Havelock-Belmont-Methune
Otonabee-South Monaghan
Smith-Ennismore
Availability:
Experience/Training:
______Years of experience in home child care
______Day - full time
______Day - part time
First Aid & CPR training:
_____/_____
______Before/after school
Y
N
______School delivery/pick-up
Formal Training
______Evenings/weekends
Family Child Care Training Certificate:
______Overnight care
Level 1 ______
Level 2 _______
Level 3_______
______Emergency/ sick child care
Care Provider Workshops:
Holiday Care: Are you available?
______March Break
______P.D. Days
Child Care will be provided in:
______Christmas break
______Care Provider’s home
______ School summer holidays
______Child’s Home
______Statutory/civic holidays
Other: __________________________________________
Wednesday, September 9, 2015
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Parent category: Legal