Application for Childcare Enrollment
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1 First Name:
*
Parent/Guardian 1 Last Name:
*
Address:
*
City:
*
Postal Code:
*
Home Phone:
Province:
Select
ON
NL
PE
NS
NB
QC
MB
SK
AB
BC
YT
NT
NU
Work Phone:
Cell Phone:
*
Email:
*
Gender:
Male
Female
Other
Relationship to Child:
*
Please select
Father
Mother
Other
Employer Name/City:
*
Parent/Guardian 2 First Name:
Parent/Guardian 2 Last Name:
Same address as Parent 1
Address:
City:
Postal Code:
Home Phone:
Province:
Select
ON
NL
PE
NS
NB
QC
MB
SK
AB
BC
YT
NT
NU
Work Phone:
Cell Phone:
Email:
Employer Name/City:
Gender:
Male
Female
Other
Relationship to Child:
*
Please select
Father
Mother
Other
Custody Arrangements (if applicable):
Are you subsidized or applying for childcare subsidy?:
*
Yes
No
Languages spoken at home:
CHILD INFORMATION
Child’s First Name:
*
Child’s Last name:
*
Gender:
*
Male
Female
Other
Date of Birth:
*
Child’s Home Address:
Same as Parent 1
Same as Parent 2
Address:
City:
Postal Code:
Province:
Select
ON
NL
PE
NS
NB
QC
MB
SK
AB
BC
YT
NT
NU
Names/ages of siblings (note: a separate application must be completed for each child):
Name and Location of Child’s school (if applicable):
General Health: Any known allergies, health or medical conditions?
*
Yes
No
If yes, please describe:
*
Does your child require any special food or liquids or any special diet?
*
Yes
No
If yes, please describe:
*
Please indicate preferred area for daycare, and outline any additional comments or requirements regarding the care of your child:
Status:
New Application
Assigned Applications
Head Office Follow-up
Head Office Declined
Registered
Agency In Progress
Application Closed
Return to HO
HOLD
Interviewing
Reviewed
SCHEDULE AND LOCATION
Date childcare required:
*
Days of the week child needs to be in care:
*
Please indicate care required:
*
Hours each day child needs to be in care:
*
Days
Evenings
Weekends
Overnights
Start Time:
*
RadDatePicker
RadDatePicker
Open the time view popup.
Time picker
Time Picker
12:00 AM
1:00 AM
2:00 AM
3:00 AM
4:00 AM
5:00 AM
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
11:00 PM
End Time:
*
RadDatePicker
RadDatePicker
Open the time view popup.
Time picker
Time Picker
12:00 AM
1:00 AM
2:00 AM
3:00 AM
4:00 AM
5:00 AM
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
11:00 PM
Varied Hours:
*
Days and Hours of the week Parent 1 works:
Closest intersection to home:
*
Closest intersection to work:
*
Days and Hours of the week Parent 2 works:
Closest intersection to home (Parent 2):
Closest intersection to work (Parent 2):
PREFERENCES
What is most important to you in selecting a childcare Provider?:
*
Are you open to place your child with a Provider with pets?
*
Yes
No
How did you hear about Wee Watch?
Friend/Family
Google
Facebook/Instagram
Print ad
Radio
Other
Describe
PHYSICIAN AND EMERGENCY CONTACTS
Physician’s Name:
*
Phone Number:
*
Persons to contact in an emergency if parents cannot be reached, and to whom the child may be released:
Full Name:
*
Phone #:
*
Relationship:
Full Name:
*
Phone #:
*
Relationship:
Full Name:
Phone #:
Relationship:
SIGNATURES
Signature of Parent/Guardian:
*
Date:
*
The agency will contact you to discuss your needs, answer your questions and advise you of the registration fee
