Family Child Care Provider Application
Please complete the following application if you are interested in becoming a Registered Home Care Provider. Fields marked with (*) are required fields.
Full Name (*)
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Address (*)
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City (*)
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Zip Code
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Telephone (*)
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E-Mail Contact
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Social Security # (*)
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County of Residence (*)
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Name of person living with you
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Age
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Relationship
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Name of person living with you
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Age
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Relationship
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Name of person living with you
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Age
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Relationship
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Name of person living with you
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Age
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Relationship
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Name of person living with you
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Age
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Relationship
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Name of person living with you
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Age
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Relationship
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Have You Ever Applied to Child Care Choices before to become a Family Child Care Provider? (*)

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If Yes Explain
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Public Elementary School where children in you area attend: (*)
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Have you and all adults (over 18) in your home lived in Ohio for at least 5 years?
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Have you or anyone living in your home ever been convicted of a crime, including misdemeanors? (*)
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Explain
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Have yoou or anyone living in your home, or any member of your family, ever been charged with, or reported for, child abuse or neglect? (*)
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Explain
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Do you have any health conditions that would affect your ability to provide a healthy and save environment for children in your care? (*)
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Explain
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Are you covered by insurance to run a family day care in your home? (*)
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Insurer
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General Background and Related Experience
High School Attended
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Year Achieved GED
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College Attended
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Area of Study
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Name of Last School or University that you attended
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Dates Attended From
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Dates Attended To
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Present Employment
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Previous Employment
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Please List all of the Children You Are currently caring for who do not live in your home
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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 Family Child Care Provider. Be sure that the addresses are complete. Child Care Choices requires receipt of 3 references to complete the registration process
Reference 1 Name
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Reference 1 Address Please Include Street City and Zip
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Reference 1 Phone
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Reference 1 Relationship
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Reference 1 Years Known
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Reference 2 Name
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Reference 2 Address Please Include Street City and Zip
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Reference 2 Phone
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Reference 2 Years Known
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Reference 3 Name
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Reference 3 Address Please Include Street City and Zip
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Reference 1 Phone
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Reference 3 Relationship
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Reference 3 Years Known
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Reference 4 Name
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Reference 4 Address Please Include Street City and Zip
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Reference 4 Phone
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Reference 4 Relationship
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Reference 3 Years Known
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To the best of my knowledge, the information I have given is true and correct. I understand the 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.
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Submit