Home Child Care Agency Application for Enrolment

Please fill out the form carefully

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For Office Use Only
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Hours of Care
Child Information
Parent Information

Custody Arrangements (if applicable)
Pick-Up Authorization
The following additional individuals are authorized to pick up my child (Photo ID will be required to confirm identify before child will be released):


Additional Emergency Information
Health Information
If yes, an individualized plan for children with medical needs must be developed between the parent and the home child care agency prior to the child’s first day of care.
Immunization Records
Please provide a copy of your child’s immunization record (e.g., yellow card) to the agency prior to your child’s first day of care. If you do not have an immunization record, please fill in the chart below. If you have chosen not to immunize your child, a Statement of Medical Exemption form or a Statement of Conscious or Religious Belief form must be completed and provided to the agency. These forms are available on the Ministry of Education’s website.
Vaccine (Age Usually Given)
Allergy Information
If yes, an individualized plan for an anaphylactic allergy that includes emergency procedures must be developed between the parent and the home child care agency prior to the child’s start date.
Dietary and Feeding Arrangements
*For children under 12 months, please complete, Appendix A: Supplementary Information for Children Under 12 Month.
Sleep Arrangements
*For children under 12 months, please also complete, Appendix A: Supplementary Information for Children Under 12 Months.
Physical Requirements
Physical Requirements



Note: ‘Parent’ is defined as a person having lawful custody of a child or person who has demonstrated a settled intention to treat a child as a child of his or her family, and includes legal guardians.
Appendix A: Supplementary Information for Children Under 12 Months

Appendix A: Supplementary Information for Children Under 12 Months
Note: According to the Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada, children up to their first birthday will be placed on their backs for sleep. This has been Health Canada’s recommendation since 1993, as a means to reduce the risk of Sudden Infant Death Syndrome (SIDS) The requirement for an infant sleep position may only be waived if a medical doctor/physician recommends differently in writing.
Government of Canada: Safe Sleep - https://www.canada.ca/en/public-health/services/health-promotion/childhood-adolescence/stages-childhood/infancy-birth-two-years/safe-sleep.html
Appendix B: Authorization for Non-Prescription, Over-the-counter Products
I understand that:
• such items will be stored in accordance with the instructions on the label.
• such containers or packages will be clearly labelled with my child’s name and the name of the item.
• such items will be administered to my child only from the original container or package and in accordance with any instructions on the label and any other instructions provided by me or another parent of my child.
Note: Consider adding the brand name of the non-prescription items for transparency.