Provider Application – click on grey portion to enter response

Applicant Information

Full Name: / Birth Date:
Last / First / M.I. / dd/mm/yyyy
Address:
Street Address / Apartment/Unit #
City / Prov. / Postal code
Phone: / () / E-mail Address:
Name of Spouse/Partner
Will this person be home during day home hours? / YES / NO
If yes, explain:

Education

High School: / Address:
From: / To: / Did you graduate? / YES / NO / Degree:
College: / Address:
From: / To: / Did you graduate? / YES / NO / Degree:
Other: / Address:
From: / To: / Did you graduate? / YES / NO / Degree:

Previous Employment

Company: / Phone: / ()
Address: / Supervisor:
Job Title:
Responsibilities:
From: / To: / Reason for Leaving:
May we contact your previous supervisor for a reference? / YES / NO
Company: / Phone: / ()
Address: / Supervisor:
Job Title:
Responsibilities:
From: / To: / Reason for Leaving:
May we contact your previous supervisor for a reference? / YES / NO
Company: / Phone: / ()
Address: / Supervisor:
Job Title:
Responsibilities:
From: / To: / Reason for Leaving:
May we contact your previous supervisor for a reference? / YES / NO / If not, why not?
Why are you interested in becoming a day home provider?
If you have provided care for children (either in a daycare/day home/or private care setting), please give details:
How long have you worked in a daycare?
Are you presently with agency? Yes No
Do you have children in your care at this time? Yes No
If yes, how many children?
Are you willing to care for children with special needs? Yes No
Do you have any experience working with special needs? Yes No
If yes, please explain:
Are you committed to working as a “partner” with Wee R Kids so that “together” we can provide quality care? Yes No
If yes, please explain why you feel it is important to work together as a team:
What does Positive Child Guidance mean to you?
What kind of behavior management strategies do you use in your home? Why do you use these particular methods?
Describe how you see your family fitting into your day home. How will they support you to make your day home a success?
Describe your centre play areas and how will they be set up:
List toys, materials, and activities that you will have available in your day home:
Do you have outdoor play equipment? Yes No
If yes, day home regulations state there must be 6 inches of protective surfacing under playground equipment (pea gravel, wood chips, etc). Are you willing to comply with this regulation? Yes No
Does anyone in your house smoke? Yes No
Day home regulations state that there shall be NO SMOKING during day home hours. Are you prepared to make the commitment of “no smoking” during day home hours, regardless if it’s indoors or outdoors? Yes No
Cigarettes, ashtrays, matches and lighters are to be locked up during hours of care. Are you willing to comply with this regulation? Yes No
Do you have pets in your home? Yes No
If yes, please list all pets:
Day home regulations state that all pets must have current immunizations. Are you willing to comply with this regulation?
Yes No
Day home regulations state that animal food and cat boxes must be made inaccessible to children. Are you willing to comply with this regulation?
Yes No
Animal feces must be picked up promptly and disposed of immediately. Are you willing to comply with this regulation?
Yes No
Have you, or anyone else living in your home, ever been party to, or involved with, any child welfare matter?
Yes No
If yes, please explain:
Have you, or anyone else living in your home, ever been party to, or involved with any form of criminal activity?
Yes No
If yes, please explain:
Do you have any supplemental employment and/or volunteer work that could affect the operation of your day home?
Yes No
If yes, please explain:
Why is it important to be non-judgmental when it comes to families and their children?
Do you understand why confidentiality is vital when providing care? Yes No
Please explain:
Have you read, and are you willing to follow the Alberta Government’s policies and regulations as set out in the “Family Day Home Program Manual” And the “Alberta Child Care Accreditation Standards?” Yes No
What are your expectations of Wee R Kids Day Home Agency? What do you want Wee R Kids to do for you?
If you become a contracted day home provider with Wee R Kids, how will you enhance our day home agency?
How would you handle the follow scenarios?
  1. A 2 year-old child scribbles on the wall with a felt pen:
  1. A 15 month-old child is biting the other children:
  1. A 3 year-old will not eat what you made for lunch: