Provider's Name	Spouse's Name

Mailing Address

Home Phone

E-mail

*required

Personal Assessment

Social Insurance no.:

Drivers License Number :

Number of Children at home :

Rent or Own the Residence :

How long have you lived there :

Questionnaire

What experience do you have in offering daycare?

Have you taken any courses relating to childcare?

Have you completed a first-aid course?

Are you currently providing daycare or registered with an agency?

Do you plan to offer daycare on a long-term basis?

Will other adults be present during the day?

Have your children's immunization shots been updated?

Would you object to a police check?

Will any additional children be in your care during the day?

Do you have any pets? Vaccinated and up to date?

Is this a non-smoking home?

Do you plan on using a car to transport children?

Who is your insurance carrier?

Any illness that may affect the care of other children?

Reference

Please list two references and their phone number not related:

Name	Number

Name	Number

Will you participate in training programmes:

Please list type of care interested in :

Full day or Half day?

Agreement

I hereby agree to the accuracy of the supplied information and give Mini-Minders consent to check the listed references. You will also be required to consent to a police check, medical and fire safety check in order to offer daycare.

Please type in security code as shown  
  23SF7