Edmonton Application Name * Phone Number: * Address: Cross Street and Avenue What type of home do you live in? Select an item House Townhouse Apartment Duplex Rented/Property managed? YN Do you have a Yard? YN Is your yard fenced? YN Days available? Hours available? Languages Spoken (other than English) Type of Pets? Non-Smoking House YN Are you willing to transport children? YN What play/child care equipment do you have? Previous Child Care Experience? What makes you interested in becoming a Dayhome Provider? What ages of children would you prefer to care for? How many? Can you give some example of activities you can do with the children? Do you have children of your own? (name, age and gender) Are you presently caring for children other than your own? YN What type of discipline do you use? Where would the children spend most of their time? How would you rate your home for cleanliness?(1-10) Have you ever been with another Dayhome Agency? How did you hear about us? Your e-mail address? Comments or Questions?

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