Home Child Care Provider Application

Contact Information

(double-check for accuracy)


Current Residence

General Questions (check any that apply)

Application date:

How would you transport a child for emergencies?

Your Home

Number of years I have lived in my home:

Number of bedrooms in my residence:

Number of other rooms in my residence:

Floors the children have access to in the home:

I have sleeping arrangements for:

Household Composition

List all adults and children in your household members. They may be part of the interview process.

Name Date of birth Relationship Home during care hours

* All adult household members will be required to complete and provide a criminal record check.


When are you available to provide home child care?


Preferred Age Range of Children

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.

Child Care Experience / Education / Training

Personal History

List all major medical problems you had in the past 10 years:

Have you or any of your family / household members been:

Do you or any of your family / household members:

Required References

Reference 1
Name Relationship
Address Phone

Reference 2
Name Relationship
Address Phone

Reference 3
Name Relationship
Address Phone

Reference 4
Name Relationship
Address Phone
Name Relationship Address Phone

I understand that:

Conditions of Application

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.

Verify your Submission

Verify your submission by typing the 6-digits you see in the box:

Type in this Number Below
* Required

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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.

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