Apply To Provide Child Care

Would you like to apply to become a Provider with TotLot Licensed Childcare?

This information will be considered ONLY if completed in full. Please answer ALL questions.

^*I live in: BarrhavenRiverside SouthManotickKanataStittsville

^*Closest main intersection to your home:

&

^*First name:

^*Last name:

^*House number & street:

^*City & postal code:

^*Best telephone number(s) to reach you at:

^*Email:

^*Please list number and types of pets in your home:

^*Do you have a pond, pool or hot tub? YESNO

^*Please note that both your home and your property must remain smoke-free, at all times (this includes free of cigarettes, cannabis, vaping, etc.), in order to have children in your care, through our Agency. Are you willing to keep your home and property smoke-free? YESNO

Please list ALL children under, 13-years-old, living in your home:

Full name

DOB

Gender

Relationship

Please list ALL children, under 13-years-old, for whom you are currently responsible during the hours you will provide day care, whether paid or unpaid (i.e. day care children, grandchildren, etc.):

Full name

DOB

Gender

Relationship

^*Are you currently working with another licensed home child care agency? If so, which one?

^*Typed signature:

^*Date: