Application to Provide Supervised Home Daycare

Form Overview

This form is to be completed by those wishing to become a licensed home child care provider with Children’s Village.

First Name *

Last Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Telephone (C)

Telephone (H)

Email Address *

Language Spoken *EnglishFrenchOther

Other Language Spoken

Child 1 Age:

Is your:SonDaughter

Providing care forYes

Child 2 Age:

Is your:SonDaughter

Providing care forYes

Child 3 Age:

Is your:SonDaughter

Providing care forYes

Child 4 Age:

Is your:SonDaughter

Providing care forYes

Child 5 Age:

Is your:SonDaughter

Providing care forYes

Please indicate if any other adults in your household are over 18 years of age:Spouse / ParentSon / DaughterRoomer / BoarderRelativeOther

Please enter a summary of your experience: *

Please do not fill in this field.

Children’s Village of Ottawa-Carleton
333 Churchill Avenue,
Ottawa, ON K1Z 5B8