CAREGIVER REGISTRATION

Name:___________________________________ Phone#:( )_____________________

Address:_____________________________ City:_____________ Postal Code:_______

Closest Main intersection:__________________________ How long at this address?______

Social Insurance #______________________ Birth Date:________________

Do you have a driver’s license? YES/NO Driver’s License#:_______________________

Auto Insurance Company:_____________________ Liability coverage amount:___________

Marital Status:__________ Spouse’s Name:___________ Spouse’s Occupation:__________

Languages Spoken:_______________________

Do you have children? YES/NO Name:__________________ Birth Date:_____________

Name:__________________ Birth Date:_____________

Name:__________________ Birth Date:_____________

Does anyone else live in your home? YES/NO Who?______________________________

Do you smoke? YES/NO Spouse? YES/NO Others?___________________________

Do you have pets YES/NO What kind?_______________________________________

Please enclose a copy of the most recent immunization.

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Home Environment House Apt. Townhouse Do you own or rent?_______

Has your home been child proofed? YES/NO What changes will you make?_________________

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Areas available to children:__________________________________________________

Equipment in Home Toys Cribs Playpen Gate Other

Outdoor areas: Are they fenced? YES/NO If not will they be? YES/NO Do you have a Pool? YES/NO

Closest Hospital:__________________ Fire Station:____________________

Public School:______________ Separate School:_________________

Library:__________________

What school does your child attend?:________________________

Are you willing to have Fire, Health and Police Inspections YES NO

Do you have any Guns? YES/NO If yes are they locked and stored correctly YES/NO

Do you (or anyone in your household) have a criminal record? YES/NO If yes, please give details:__

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Day Care Experience

(1) Have you ever provided Home Daycare before? YES/NO If yes for how long?__________

(2) List child related experiences:______________________________________________
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(3) What types of activities would your Daycare Day include?:

For infants:__________________________________________________________

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For toddlers:________________________________________________________
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For preschool:_______________________________________________________

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For school aged:_____________________________________________________
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(4) What television programs do you feel are appropriate for children?:________________
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(5) How much T.V. would you allow per day?____________________________

(6) If a child in your care bit another child, how would you handle the situation?:____________

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(7) If a child in your care suffered an injury, how would you handle it, if it was:

(a) minor:____________________________________________________________
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(b) serious:___________________________________________________________
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Do you have first aid or CPR training? YES/NO Details:___________________________

Age group preference?___________________ Full Time? YES/NO What hours?_______

Part Time? YES/NO What days and/or hours?________________

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I certify that the information I have supplied on this application is correct and that KIDDIE KARE may further investigate of verify this information. I have submitted two references, preferably relating to day care experiences (not family members). NOTE: Prior to starting care a criminal reference check for all adults living in the home must be completed. To arrange one call 905-453-2121.

BY SIGNING BELOW I AGREE THAT I WILL NOT ATTEMPT TO MAKE PRIVATE ARRANGEMENTS WITH PARENTS INTERVIEWED THROUGH THE AGENCY.

___________________________________ _______________

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Date App. Rec.:_________________ Acknowledged

Start Date:________________ Termination Date:____________________

Date of Safety Check:_____________________ Available spaces and Ages:___________

Approved By:_____________________________ Date:_______________________

Name: _________________________________

Address _________________________________

Telephone _________________________________

Health Card No _________________________________

Name of Doctor _________________________________

Address _________________________________

Telephone _________________________________

What major illnesses, accidents, or operations have you had in the last year?______________

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Do you suffer from:
Allergies Asthma Diabetes Epilepsy

Back Problems Other: _____________________________

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Do you suffer any emotional or physical disabilities that would interfere with the care of the care of the child? YES/NO

If yes, please describe:_________________________________________________________

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Date of last

Small-Pox Vaccination: _____________________________

Mumps, Measles, and Rubella _____________________________

Poliomyelitis Vaccination _____________________________

Chest X-ray _____________________________

Tetanus Injection _____________________________

T.B. Test _____________________________

Date of last medical check up _____________________________

General Comments:
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