Provider Application Form

Licensed Home Child Care Provider Application (Ontario CCEYA Compliance)

Applicant Information

Full Legal Name (as per government ID):

Preferred Name (if different):

Date of Birth (DD/MM/YYYY):

Gender:

Languages Spoken/Written:

Address:

City:

Province:

Postal Code:

Please enter a number from 0 to 9.

Phone (Home):

Cell:

Email:

Closest Major Intersection:

Years at This Address:

Driver’s License / Government ID #:

Status in Canada (Citizen / PR / Work Permit):

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Social Insurance Number:

Child Care Experience & Training

Reasons for wanting to provide home child care:

Previous child care experience (include years, ages, type of care):

Currently caring for children? (Yes/No, if yes, how many and ages):

Other employment/professional experience:

ECE/RECE diploma (Yes/No, Registration # if yes):

Child Development/Behaviour Guidance Training (Yes/No):

Special Needs/Inclusive Care training (Yes/No):

Food Handler’s Certificate (Yes/No):

WHMIS/Health & Safety Training (Yes/No):

Other relevant training:

Willing to complete mandatory orientation training (Yes/No):

Health & Safety Requirements

Standard First Aid & CPR Level C (valid, non-expired)

Annual Health Assessment by physician/nurse practitioner

Immunization Record (Tetanus, TB, MMR, as per Public Health)

Willingness to follow communicable disease protocols (COVID-19, flu, sanitization)

Home Environment & Safety Compliance

Smoke-free environment during child care hours
Functional smoke detectors and carbon monoxide detectors (all levels)
Fire extinguisher present and inspected annually
Fire evacuation plan posted and practiced monthly with children
First Aid kit available and stocked
Cleaning supplies and hazardous materials stored locked/unreachable
Medications stored in locked cabinet
Weapons/firearms prohibited in child care environment
Safe sleep practices for infants (no blankets/pillows/unsafe cribs)
Pools/hot tubs inaccessible with locked gate/cover if present
Pets vaccinated and safe with children
Home liability insurance (minimum $2 million recommended)

Household Members

All residents must be declared. Children under 4 count towards ratio. Children 4–17 must be listed for supervision and safety. Adults 18+ require PVSC & Medical Clearance.

Children Under 4 Years Old

Name:

Relationship:

DOB:

Name:

Relationship:

DOB:

Children Under 4 Years Old

Name:	Relationship:	DOB:	Actions

There are no Entries.

Children Under 5-17 Years Old

Name:

Relationship:

DOB:

Name:

Relationship:

DOB:

Children Under 4 Years Old

Name:	Relationship:	DOB:	Actions

There are no Entries.

Adults 18+ Years

Name:

Relationship:

DOB:

PVSC Status:

Completed

Pending

Not Provided

Untitled

Name:	Relationship:	DOB:	PVSC Status:	Actions

There are no Entries.

Availability & Program Preferences:

Full-Time

Part-Time

Availability & Program Preferences:

Days

Evenings

Weekends

Overnight

Age Groups:

0–2 yrs

2–3 yrs

4–6 yrs

6–12 yrs

Maximum number of children you can accommodate:

Program Compliance Requirements:

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Availability & Program Preferences:

Maintain daily attendance logs

Keep menus and activity plans up-to-date

Complete serious occurrence reports as required by CCEYA

Maintain confidential records of children/families

Participate in inspections by Ministry and Agency

Provide safe transportation (if applicable: license, insurance, car seats)

Participate in ongoing professional development and training

References:

Name:

Relationship:

Phone:

Email:

Name:

Relationship:

Phone:

Email:

Required Documentation (Attach Copies):

Availability & Program Preferences:

Police Vulnerable Sector Check (all 18+ household members)

Health Assessment (provider and household members if required)

Standard First Aid & CPR (Level C)

Immunization Records (provider & children in home)

Proof of Address (ownership/lease/utility bill)

Proof of Home & Liability Insurance

Fire Safety Checklist (signed)

RECE Registration (if applicable)

Provider Declaration:

I, , declare that the information provided is true and accurate. I agree to comply with the Child Care and Early Years Act, 2014 (CCEYA), O. Reg. 137/15, Murfat Home Child Care agency policies, and all Public Health and Fire Safety regulations.

Signature:

Date

File

Drop files here or

Max. file size: 3 GB.

For Agency Use Only:

Date Application Received:

Interview Date:

Interview Conducted By:

Site Safety Inspection Completed (Yes/No):

Yes

Notes:

Start Your Registration

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FAQS

Find All your Answers Here

What are your hours of operation?

We are open Monday through Friday from 7:00 AM to 5:00 PM.

What ages do you accept?

From 3 Months – 5 Years

Is your home day care licensed?

Yes! It is licensed.

What is your provider-to-child ratio?

Our provider-to-child ratio is 1:6.

Maximum of 3 children under 2 years old.
Maximum of 2 infants.

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Licensed Home Child Care Provider Application (Ontario CCEYA Compliance)

Applicant Information

Child Care Experience & Training

Health & Safety Requirements

Home Environment & Safety Compliance

Household Members

Children Under 4 Years Old

Children Under 5-17 Years Old

Adults 18+ Years

Availability & Program Preferences:

Program Compliance Requirements:

References:

Required Documentation (Attach Copies):

Provider Declaration:

For Agency Use Only:

Start Your Registration

Stay connected, feel free to connect

FAQS

Find All your Answers Here

Main Menu

Subscribe Newsletter & Get Our News

Stay connected, feel free
to connect