Type of Care Requested

Expected Hours of Care (daily):

Hours of Care:

Child Information

Parent Information

Parent 1

Parent 2 (Optional)

Custody Arrangements (if applicable)

Emergency Contacts # 1:

Emergency Contacts # 2:

Emergency Contacts # 3:

Health Information

Immunization Records

Please provide a copy of your child’s immunization record (e.g., yellow card) to the agency prior to your child’s first day of care. If you do not have an immunization record, please fill in the chart below.

If you have chosen not to immunize your child, a Statement of Medical Exemption form or a Statement of Conscious or Religious Belief form must be completed and provided to the agency. These forms are available on the Ministry of Education’s website.

Allergy Information

Dietary and Feeding Arrangements

*For children under 12 months, please complete, Appendix A: Supplementary Information for Children Under 12 Month.

Sleep Arrangements

*For children under 12 months, please also complete, Appendix A: Supplementary Information for Children Under 12 Months.

Physical Requirements

Additional Information

Note: ‘Parent’ is defined as a person having lawful custody of a child or person who has demonstrated a settled intention to treat a child as a child of his or her family, and includes legal guardians.

Appendix A: Supplementary Information for Children Under 12 Months

Sleep Arrangements

Note: According to the Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada, children up to their first birthday will be placed on their backs for sleep. This has been Health Canada’s recommendation since 1993, as a means to reduce the risk of Sudden Infant Death Syndrome (SIDS)2

The requirement for an infant sleep position may only be waived if a medical doctor/physician recommends differently in writing.

Appendix B: Authorization for Non-Prescription, Over-the-counter Products

Understand that:

• Such items will be stored in accordance with the instructions on the label.
• Such containers or packages will be clearly labelled with my child’s name and the name of the item.
• Such items will be administered to my child only from the original container or package and in accordance with any instructions on the label and any other instructions provided by me or another parent of my child.

Note: Consider adding the brand name of the non-prescription items for transparency.

CONSENT FORM

PHOTO PERMISSION:

I give permission for my child to be photographed while attending childcare and for permission to use in promotional materials

CONFIDENTIALITY:

This childcare will respect the confidentiality between the agency and the families childcare is provided for. Information regarding parents and their children will be held in the strictest confidence both during and after the provision of childcare services. It is necessary for you to feel free to confide in your provider in order to maximize benefits to all involved. Parents will also be held to strict confidentiality regarding other families in the provider’s care. Making false or damaging statements about this childcare, the provider or other families in care will result in immediate termination of this contract and may be actionable in a court of law.

ADMINISTERING OVER THE COUNTER MEDICATIONS:

I authorize to administer over the counter medications provided by me to my child as instructed by me in writing, in accordance with the label, as needed. Children’s fever reducers i.e. Tylenol, Advil generic brand.

Withdrawal Notice:

As part of my child enrollment agreement, I am obligated to give 2 WEEKS Notice for my Child to Withdraw/End care agreement with MURFAT HOME DAY CARE.

Parent Handbook:

The parent agrees to comply with the parent handbook of MURFAT HOME CHILD CARE that will be provided to the parents after the completion of the Application process.

APPENDIX C: FEE AGREEMENT

Murfat Home Child Care – 2025 CWELCC Fee Schedule: Canada-Wide Early Learning and Child Care Program (CWELCC)

Murfat Home Child Care (MHCC) is proudly enrolled in the Canada-Wide Early Learning and Child Care (CWELCC) system under the Ontario Ministry of Education. Our 2025 rates reflect the new provincial fee cap of $22 per day for all eligible children under 6 years of age. These rates are designed to make high-quality, licensed home child care affordable while maintaining the highest standards of safety, education, and nurturing care.

Important CWELCC Updates for 2025:

1. New Provincial Fee Cap
   As of January 1, 2025, Ontario has implemented a maximum daily fee of $22.00 for all licensed CWELCC-enrolled child care programs for eligible children under 6.
2. Eligibility
   The CWELCC fee reductions apply only to:
   • Children under 6 years old
   • Your child is eligible for a CWELCC fee reduction until the last day of the month they turn 6 Years.
3. Cost-Based Funding Model (2025 Forward)
   Ontario is now using a cost-based funding model to support CWELCC programs. This ensures that agencies like MHCC can maintain quality standards, staff training, and safe environments while keeping fees capped at $22/day.
4. Future Fee Reductions Goal
   The federal-provincial plan aims to reduce the average parent fee to $10/day by 2026, improving affordability and accessibility across Ontario.

Appendix C: List of Communicable Diseases

• Acquired immunodeficiency syndrome (AIDS)
• Chancroid
• Chlamydia trachomatis infections
• Creutzfeldt-Jakob disease, all types
• Cytomegalovirus infection, congenital
• Encephalitis
• Gonorrhea
• Hemorrhagic fevers
• Hepatitis B
• Hepatitis C
• Influenza
• Legionellosis
• Leprosy
• Meningitis, acute
• Ophthalmia neonatorum
• Personal service settings
• Respiratory infections, including institutional outbreaks
• Severe acute respiratory syndrome (SARS)
• Streptococcal infections
• Syphilis
• Tuberculosis

Regulatory Requirements: Ontario Regulation 137/15

Children’s Records

72(1) Every licensee shall ensure that up-to-date records are kept of the following matters in respect of each child receiving child care at a child care centre operated by the licensee or receiving child care at a premises where it oversees the provision of home child care:

1. An application for enrolment signed by a parent of the child.
2. The name, date of birth and home address of the child
3. The name, date of birth and home address of the child
4. Revoked
5. The names of persons to whom the child may be released.
6. The date of admission of the child.
7. The date of discharge of the child
8. The child’s previous history of communicable diseases, conditions requiring medical attention and, in the case of a child who is not in attendance at a school or private school within the meaning of the Education Act, immunization or required form completed by a parent or legally qualified medical practitioner as to why the child should not be immunized.
9. Any symptoms indicative of ill health.
10. (1) A copy of any individualized plan
11. Written instructions signed by a parent of the child for any medical treatment or drug or medication that is to be administered during the hours the child receives child care.
12. Written instructions signed by a parent of the child concerning requirements in respect of diet, rest or physical activity
13. A copy of any written recommendation referred to in subsection 33.1 (1) from a child’s physician regarding the placement of a child for sleep.
    • (2) The records listed in subsection (1) shall be kept, as the case may be,
    • (a) omitted – refers to child care centres
    • (b) at the home child care premises where the child receives child care and at the home child care agency overseeing the provision of such care.
    • (3) Every licensee shall ensure that a record is kept of the daily attendance of each child receiving child care in each child care centre it operates and in each premises where it oversees the provision of home child care showing the time of arrival and the time of departure of each child or if a child is absent.
    • (4) Every licensee shall ensure that a record is kept of the daily attendance of each child in a licensed age group, including each child who was in the group each day and the hours during which they were in the group.
    • (5) Every licensee shall ensure that the records required to be maintained under this section with respect to a child are kept for at least three years from the date the child is discharged at the child care centre or home child care agency.

Disclaimer: This document is a sample template that has been prepared to assist licensees in understanding their obligations under the CCEYA and O. Reg. 137/15. It is the responsibility of the licensee to ensure that the information included in this document is appropriately modified to reflect the individual circumstances and needs of each home child care agency it operates and each premises where the licensee oversees the provision of home child care.

Please be advised that this document does not constitute legal advice and should not be relied on as such. The information provided in this document does not impact the Ministry’s authority to enforce the CCEYA and its regulations. Ministry staff will continue to enforce such legislation based on the facts as they may find them at the time of any inspection or investigation.

It is the responsibility of the licensee to ensure compliance with all applicable legislation. If the licensee requires assistance with respect to the interpretation of the legislation and its application, the licensee may wish to consult legal counsel.