Approved Family Child Care Provider Application

Applicant Name*
Address*
Postal Code*
Contact Number*
Email*
Name of spouse/partner (if applicable)
Place of Employment
Hours of Work
Marital Status (Please check the appropriate box)*
- Married
- Separated
- Divorced
- Single
- Common-law
- Widowed
Own Children
Child 1 - Name*
Child 1 - Date of Birth*
Child 1 - Sex*
- Male
- Female
Child 1 - Immunizations Up To Date?*
- Yes
- No
Child 2 - Name
Child 2 - Date of Birth
Child 2 - Sex
- Male
- Female
Child 2 - Immunizations Up To Date?
- Yes
- No
Child 3 - Name
Child 3 - Date of Birth
Child 3 - Sex
- Male
- Female
Child 3 - Immunizations Up To Date?
- Yes
- No
Other people (relatives, borders) living at home
Other Person 1 - Name
Other Person 1 - Relationship
Other Person 1 - Age
Other Person 1 - Involved with child care?
- Yes
- No
Other Person 2 - Name
Other Person 2 - Relationship
Other Person 2 - Age
Other Person 2 - Involved with child care?
- Yes
- No
If the above are involved in child care, in what way? (if Yes for more than 1 person, give specific details per person):
Are you caring for any children other than your own at this time?*
- Yes
- No
If Yes, specify number and ages of children
If No, have you provided child care in the past?
- Yes
- No
If you did, for how long and what was the age range of the children?
What type of dwelling do you live in? (Please check the appropriate box)*
- single
- duplex
- apartment
- condo
- 4plex
- mobile home
If you are renting we require a letter from your landlord:*
- Own
- Rent
Do you have a fenced yard?*
- Yes
- No
Why are you interested in operating an approved family day home at this time?*
How would you describe the support from your family i.e. spouse/partner and children for your day home operation?*
Formal education completed*
What Languages do you speak?*
Previous Employment (list name of employer, number of years worked and position/Duties- begin with most recent employment):*
Do you have a Child Development Certification Level (if so which) or are you expecting an equivalency from a current degree/diploma?*
Have you inquired with or been approved by another Family Day Home Agency previously?*
If so do you give us permission to contact them as a reference?
- Yes
- No
Do you or anybody in your household smoke?*
- Yes
- No
Do you have pets?*
- Yes
- No
If you have pets, what kind?
How many children do you wish to care for excluding your own children?*
What preference do you have in regards to ages of children you wish to care for? Please check appropriate boxes*
- Infants
- toddlers
- pre-schoolers
- school age
What preference do you have in regard to sex of the children?*
Any specific reason(s) for your preferences?*
Are you willing to provide care for children with special needs?*
- Yes
- No
Please explain*
Are you willing to transport children in your own vehicle?*
Between what hours and on what days would you generally be available to provide care?*
Would you be willing to consider extended hours of care?*
- Yes
- No
If yes, check whichever is applicable
- weekend's
- evenings
- overnight
- Statutory holiday’s
Are there any medical problems you or any of your family members have which may effect your ability to provide child care?*
- Yes
- No
If Yes, please explain
In the past 2 years did you or any of your family need professional assistance with:
Marital problems*
- Yes
- No
Emotional problems*
- Yes
- No
Behavioural problems*
- Yes
- No
If yes for any of these, please explain
Have you or any in your family ever been charged with a crime involving assault?*
- Yes
- No
If Yes, please explain the situation
Have you ever been a party to or involved with any child welfare matter?*
- Yes
- No
If Yes, please describe the situation and how you were involved
Unless unforeseen circumstances happen, for how long are you willing to commit to operate a day home?*
- 1 year
- 1 to 3 years
- over 3 years
Are you willing to follow all standards as stated in the Family Day Home Standards Manual by the Government of Alberta?*
- Yes
- No
If so, have you read the manual?*
- Yes
- No
Are you willing to abide by all agency set policies including the home approval process and required monthly visits by a consultant for so long as you are contracted?*
- Yes
- No
Please list names of three professional references who could comment on your personal suitability as a caregiver for young children, on your parenting and/or on your character. These people must not be relatives or friends and you should have known them for at least one year. We require postal codes as these will be mailed out.
Name - Reference 1*
Address - Reference 1*
Phone # - Reference 1*
Name - Reference 2*
Address - Reference 2*
Phone # - Reference 2*
Name - Reference 3*
Address - Reference 3*
Phone # - Reference 3*
By submitting this application I certify that all of the information reported on this application is true to the best of my knowledge and I understand that this application does not guarantee that my day home will be approved by this agency.

Should my application become void or I do not want to contract with this agency, I will notify the agency staff immediately and all of my information will be shredded or returned to me at my request.
I agree*
- Yes
Date submitted*
MM slash DD slash YYYY

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Own Children

Other people (relatives, borders) living at home

In the past 2 years did you or any of your family need professional assistance with: