Child Care Choices Application to become a Registered Home Provider...
Complete ONLY if you are interested in providing child care in Crawford, Marion, Morrow or Richland counties in Ohio.

Personal Information

Full Name:
Address:
City:
State:
Zip:
Phone:
Email:
Date of Birth:
Social Security #:
County of Residence:

List all persons living in your home

Adults (over 18)          
Name: Age: Relationship:
Name: Age: Relationship:
Children (under 18)          
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:

Total Number of Adults:   
Total Number of Children:         

Answer the following questions

Have you ever applied to Child Care Choices to become a Home Provider before?
Yes:
No:
Are you currently Licensed with any other agency for child care?
Yes: Explain:   
No:
Public Elementary School where children in your area attend:   
Have you and all adults (over 18) in your home lived in Ohio for at least 5 years?
Yes:
No:
Have you or anyone living in your home ever been convicted of a crime, including misdemeanors?
Yes: Explain:   
No:
Have you, anyone living in your home or any member of your family ever been charged with, or reported for child abuse or neglect?
Yes: Explain:   
No:
Do you have any health conditions that would affect your ability to provide a healthy and safe environment for children in your care?
Yes: Explain:   
No:
Are you covered by insurance to run a family day care in your home?
Yes: Insurer:    
No:

General Background and Related Experience

Education:

High School:       Name of School:
GED (Year achieved):
College:
Other:
Major area of study:
Name of last school or university that you attended:
Dates Attended - From:    To:

Present or Most Recent Jobs:

Company Name Complete Address Supervisor Phone Hired From: Hired To: Responsibilities Reason for leaving

Describe your past experience in working with children other than your own:

Children you are caring for - List all children for whom you are currently caring, who do not live in your home

Full Name: Age: Phone:
Full Name: Age: Phone:
Full Name: Age: Phone:

Full Name:

 Age: Phone:
Full Name: Age: Phone:
Full Name: Age: Phone:

References -
List 4 individuals (who are not related to you) who can give a reference concerning your character and general qualifications for the job of a Registered Home Provider.  (Please be sure the addresses are complete).  Child Care Choices requires receipt of 3 references to complete the registration process. 

Name Address City State Zip Phone Relationship Yrs Known

To the best of my knowledge, the information I have given is true and correct.  I understand that any false information would be grounds for immediate termination of my home registration and any parent using my service may be notified.  I also understand that references may be sent to employer’s where I worked with children and I authorize them to complete a reference.
I agree:           I disagree:

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