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(double-check for accuracy)
I own my current residence
I am renting my current residence
I have renter's insurance
I have my landlord's approval to be a care provider
I, or someone in my family, have applied to be a home child care provider and been rejected
Reason for rejection:
I have previously / am currently providing home child care in my home
I have received government funding for providing home child care
Through a licensed home child care agency
I am over 18 years of age
I am legally entitled to work in Canada
I have a valid driver's licence
I have vehicle insurance required to drive in Ontario
I do not drive
I have limitations in serving as a child care provider
How would you transport a child for emergencies?
How did you hear about Niagara Region's Home Child Care program?
Number of years I have lived in my home:
Number of years
Less than 1
1 - 2
3 - 4
5 or more
Number of bedrooms in my residence:
Number of bedrooms
10 or more
Number of other rooms in my residence:
Number of other rooms
10 or more rooms
Floors the children have access to in the home:
My home has an outdoor play space
I have sleeping arrangements for:
Both females and males
List all adults and children in your household members. They may be part of the interview process.
* All adult household members will be required to complete and provide a criminal record check.
List other adults (over 18) who will regularly visit the home during the hours of care:
I have frequent visitors/overnight guests
When are you available to provide home child care?
Infants (Birth - 18 months)
Toddlers (18 - 30 months)
Pre-schoolers (30 months - 5 years)
School aged (6 - 12 years)
Note: A maximum of five children can be in care at any given time in home child care. Age mixes and inclusion of the caregiver's own children in that count are governed by the regulations set out under the Day Nurseries Act and Policies of Niagara Region, and vary based on specified parameters.
Graduated from high school
Graduated from college or university
Other education / training related to child care
Related child care experience
Why do you want to provide home child care?
List all major medical problems you had in the past 10 years
List any medication you are currently on
Have you or any of your family / household members been
Treated for or had emotional / psychiatric problems
Treated for or had a drug or alcohol-related problem
Involved with Family and Children's Services
Do you or any of your family / household members
Drinks per week:
I understand that:
Niagara Region will contact the above individuals to provide a reference supporting my application
Written references from these individuals must be available if an interview is granted
A consent form must be signed by everyone over the age of 18 who lives in the home
I have read and understand the conditions of application
I hereby certify that all the information provided on this application and/or any attachment hereto is correct and that any false statement or deliberate omission of a material fact made by me on this application and/or any attachment hereto or in the recruitment or selection process may be sufficient cause for rejection of the application by the Niagara Region Licensed Home Child Care Program.
I authorize any review of my experience and education details, and verification of all data given herein, in documentation provided by me, and given verbally by me at any related interview. I release from liability any person giving or receiving such information.
I agree to provide the Niagara Region Licensed Home Child Care Program with a current criminal reference check, medical information for myself and all individuals over the age of eighteen years residing in my home, as well as, a fire inspection of the home conducted by the local fire department. Should I be approved to provide child care in my home, such requirements will be at my own expense unless otherwise specified in writing by the Program.
Note: Applications will be kept on file for six months. It is the responsibility of the applicant to ensure that his/her application is renewed after the six month period.
Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.
Freedom of Information
Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.
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