Home Childcare Provider Application Name * First Name Last Name DOB * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Cell Phone * (###) ### #### Home Phone * (###) ### #### Do you have reliable access to video calls? * Yes No Please indicate what platform you use. * e.g. Zoom, Google Meet, Facetime, Whats App. Do you have a personal printer? * Yes No What languages do you speak? * What languages do you understand? * What languages can you read and write? * Do you have a valid FirstAid/CPR level C certification? * Yes No First Aid/CPR Expiry Date MM DD YYYY AVAILABILITY What days are you available to provide care? * Preferred start time/close time * Are you available to work extended hours (10+ hours per day)? * Yes No Evenings? * Yes No Overnights? * Yes No Public Holidays? * Yes No Are you willing to care for school aged children? * This may include before & after school, PD days, breaks and holidays. Yes No Do you have an approved alternate provider who can provide care when you are unavailable? * A neighbour or close family/friend who can step in during an emergency. Yes No FAMILY/HOME Marital Status * Spouse’s Name & Occupation Do you have children? If YES: Children's names/genders/date of birth. Your Children’s School Does anyone else live in your home? * Yes No If so, who? Do you or anyone in your house smoke? * Yes No If so, who? Do you have a pet? * Yes No What kind of animal? Last vaccination date MM DD YYYY Type of home? * Apartment Townhouse/Semi-Detached Single Home What areas in your home will the children have access to? * What space do you have available for outdoor play? * Closest Park(s) * Closest Library * Closest Public/Separate School * Closest Hospital * Do you or anyone in your household have a criminal record? Answer: YES / NO If yes, please give details. * WORK EXPERIENCE/EDUCATION Please list any education you have received and/or completed * e.g. University, College, Trainings, Workshops or Certifications. Have you ever been a Home Childcare Provider before? * Yes No Reasons for wanting to Provide Childcare: * What experiences have prepared you to be a licensed Home Childcare Provider? * Do you have experience with children who have special needs and/or medical needs? * What type of activities would you plan for children in your care? * REFERENCES Please provide 3 references. e.g. Friend, neighbour, work (childcare if possible), parents of children you have provided care for. Reference 1: * First Name Last Name Phone * (###) ### #### Email * Relationship * Reference 2: * First Name Last Name Phone * (###) ### #### Email * Relationship * Reference 3: * First Name Last Name Phone * (###) ### #### Email * Relationship * I certify that the information I have supplied on this application is correct, and agree that RFC Home Childcare may contact the references listed above should I choose to move forward with this application process with the agency. * Yes No Today's Date: * MM DD YYYY Signature * Thank you for applying to be a Home Childcare Provider. We will get back to you soon!