Provider Application
PROVIDER INFORMATION
First Name:
*
Last Name:
*
Gender:
*
Male
Female
Other
Address:
*
Date of Birth:
*
Unit:
Languages spoken:
City:
*
Email Address:
*
Postal Code:
*
Phone:
Province:
*
Select
ON
NL
PE
NS
NB
QC
MB
SK
AB
BC
YT
NT
NU
Cell:
*
Closest main intersection:
Status:
New Application
Assigned Applications
Head Office Follow-up
Head Office Declined
Registered
Agency In Progress
Application Closed
Return to HO
HOLD
Interviewing
Reviewed
Years at this address:
Emergency Contact Name:
*
Emergency Contact Phone:
*
Relation To Provider:
*
CHILD CARE EXPERIENCE
Reasons for wanting to Provide home childcare:
*
Describe any previous childcare experience you have:
*
Are you currently caring for children in your home?:
*
Yes
No
If yes, how many and what ages?:
*
List other work experience:
Are you fully vaccinated for COVID-19:
*
Yes
No
Exemption
Partial
Comment:
Are you a Registered Early Childhood Educator (RECE)?:
*
Yes
No
Registration:
Do you have Standard First Aid certificate and CPR Level C? :
*
Yes
No
Expiry Date:
How did you hear about WeeWatch?:
Friend/ Family
Google
Facebook/Instagram
Print
Radio
Indeed/job posting
Other
Describe:
SCHEDULE AND PREFERENCES
What hours do you want to work?:
*
Full Time
Part Time
What hours would you work?:
*
Days
Evenings
Weekends
Overnights
What ages of children would you prefer to care for? :
HOUSEHOLD INFORMATION
Type of Home:
*
House
Apartment
Townhouse
Ownership:
*
Own
Rent
If you rent, have you notified your Landlord that you want to operate home childcare?
Yes
No
Are outdoor areas fenced?
*
Yes
No
N/A
Do you have a pool?
*
Yes
No
Do you have a pets?
*
Yes
No
Types of Pets:
Does your home have an apartment/unit with tenants?
Yes
No
If Yes, does the apartment/unit have a locked door between units or a separate entrance?:
Yes
No
Closest school(s):
Would you be willing to walk to and from school with children in care?:
*
Yes
No
List all residents living in your home:
Spouse/Partner, Name:
Date of Birth:
List all person(s) above 13 years old living in the home
First Name:
Last Name:
Relation to Provider:
Select
Spouse/Partner
Child
Other
Date of Birth:
Please click save after entering each person
Is everyone in your household over 18 fully vaccinated for COVID-19?
Comment:
Do you or anyone living in the home smoke (tobacco/marijuana)?
Yes
No
Do you or anyone in your household have a criminal record?
Yes
No
Criminal Records Comment
List all person(s) under 13 years old living in the home
First Name:
Last Name:
Gender:
Male
Female
Other
Date of Birth:
Please click save after entering each child
REFERENCES
We require 4 references, a friend, a neighbor, family member (not living with you), previous employer or work related:
Name:
*
Phone #:
*
Address:
Relationship:
Email:
*
REFERENCE 2
Name:
*
Phone #:
*
Address:
Relationship:
Email:
*
REFERENCE 3
Name:
Phone #:
Address:
Relationship:
Email:
REFERENCE 4
Name:
Phone #:
Address:
Relationship:
Email:
SIGNATURE
I certify that the information I have supplied on this application is correct, and agree that Wee Watch may verify this information and contact the reference list above in connection with my proposed relationship with the agency
Signature:
*
Date:
*
Once you have completed this form, please contact the local Wee Watch Agency to inquire about their application process and the application fee.