Name
Are you over 18 years of age?
YesNo
Home Phone
Email
Address
—Please choose an option—AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
Type of home?
—Please choose an option—ApartmentCondominiumDuplex/TownhouseHouse
Community
Do you have a fenced yard?
Do you or anyone in your home smoke?
What are the closest schools to you?
What ages of children would you prefer to care for?
Currently employed?YesNo
[group employed-now-selected]
Employment
—Please choose an option—CasualContractFull-timePart-timeSeasonalTemporary
Employer
[/group]
Please leave this field empty.
Are you on social assistance?YesNo
Mon
—Please choose an option—07:00 am07:30 am08:00 am08:30 am09:00 am09:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm01:00 pm01:30 pm02:00 pm02:30 pm03:00 pm03:30 pm04:00 pm04:30 pm05:00 pm05:30 pm06:00 pm
Tue
Wed
Thu
Fri
Would you be available to provide evening care?YesNo
Do you have any children?YesNo
[group child-status-selected]
Please list all children
Do you have any pets?YesNo
Why are you interested in joining a family day home agency?
Have you applied to and/or worked with another day home agency?YesNo
Do you have any work experience in childcare?YesNo
What sort of activities would you plan with the children?
Do you have first aid certification?YesNo
Could you provide 3 childcare references if needed?YesNo
Do you own any essential child care items (crib/highchair/stroller)?YesNo
How did you hear about ERCCA Northalta? —Please choose an option—ERCCA Northalta WebsiteFriend ReferralGoogle SearchGovernment of ABSocial MediaOther
I understand that data will only be used for the purpose it was collected for and which I consented to
