Parent Intake Package

Complete all forms below and submit at once

Your Information (required for submission)

Parent / Guardian Name *

Email *

Child's Name

Parent-Agency Agreement

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

Parent-Agency Agreement

Licensed Home Child Care Services Agreement

Agreement Between

Parent/Guardian Name

Parent/Guardian Address

Parent/Guardian Email

Child's Name

Child's Date of Birth

Start Date of Care

Provider Name

1. Services Provided

Kids Lives Matter Licensed Home Childcare Agency ("Agency") agrees to provide licensed home childcare services through approved providers to the enrolled child(ren) listed above.

Services include:

Supervision and care by licensed providers in approved home settings
Age-appropriate activities promoting physical, social, emotional, and cognitive development
Nutritious meals and snacks (as outlined in care plan)
Safe and clean environment meeting all regulatory standards
Regular communication regarding child's progress and well-being
Emergency care protocols and first aid certified staff

2. Schedule and Hours of Care

Days of Care

Hours of Care

Note: Any changes to schedule must be communicated at least 2 weeks in advance and are subject to provider availability.

3. Payment Terms

Payment Plan

Fee (plus HST)

Payment Due Date

Payment Policy:

Payment is due according to the selected payment plan (weekly, biweekly, or monthly)
All fees are subject to HST
Late payments (after 5th of payment period) will incur a $45 late fee
Payment is required for statutory holidays and sick days
One month notice required for vacation
Non-sufficient funds (NSF) will incur a $45 fee
Failure to pay may result in termination of services

4. Parent/Guardian Responsibilities

Provide accurate and complete information about the child's health, allergies, and special needs
Update emergency contacts and medical information promptly
Ensure child arrives with necessary supplies (diapers, wipes, extra clothing, etc.)
Inform provider of any changes in child's health, medication, or family circumstances
Pick up child on time; late pick-ups may incur additional fees ($1/minute for the first 5 minutes, $2/minute after 5 minutes)
Keep child home when ill to prevent spread of illness to others
Maintain open and respectful communication with provider and agency
Review and sign all required forms and policies

5. Agency Responsibilities

Ensure all providers are properly licensed and meet provincial regulations
Conduct regular inspections and quality assurance visits to provider homes
Provide support, training, and resources to childcare providers
Maintain current liability insurance coverage
Address parent concerns and complaints in a timely and professional manner
Ensure providers maintain safe, clean, and appropriate environments
Coordinate emergency procedures and protocols
Facilitate communication between parents and providers

6. Health and Safety Compliance

The Agency and Provider commit to:

Maintaining current First Aid and CPR certification
Following all health and safety regulations as per provincial legislation
Implementing illness and exclusion policies to protect all children
Conducting daily health checks and monitoring children's well-being
Maintaining emergency evacuation plans and conducting regular drills
Ensuring all equipment and toys meet safety standards
Following food safety guidelines and allergy management protocols
Reporting any incidents or injuries to parents immediately

7. Termination of Agreement

This agreement may be terminated by:

Parent: With 4 weeks' written notice to the Agency
Agency: With 4 weeks' written notice for non-payment, policy violations, or irreconcilable concerns
Immediate termination may occur for:
- Threatening or abusive behavior toward provider or staff
- Repeated non-payment of fees
- Providing false or misleading information
- Failure to comply with health and safety requirements

Notice Period: Payment is required for the full notice period regardless of attendance.

8. Confidentiality and Privacy

The Agency and Provider will maintain confidentiality of all personal information about the child and family in accordance with applicable privacy legislation.

Information may only be shared with:

Authorized emergency contacts listed by the parent
Medical personnel in case of emergency
Regulatory authorities as required by law

9. Liability and Insurance

The Agency maintains liability insurance coverage for all licensed childcare operations. Parents acknowledge that reasonable care will be taken to prevent accidents, but the Agency and Provider are not liable for injuries resulting from normal childhood activities or incidents beyond their control.

Parents are responsible for ensuring their child has adequate health insurance coverage.

Acknowledgment and Consent

I have read and understand all terms and conditions of this Parent-Agency Agreement

I have reviewed all agency policies including health, safety, payment, and termination policies

I confirm that all information provided is accurate and complete

I agree to make payments on time according to the terms outlined above

I agree to cooperate with the Agency and Provider in providing quality care for my child

Signatures

Parent/Guardian Name (Print)

Parent/Guardian Signature

Date

Agency Representative Name

Agency Representative Signature

Date

Email to Parent:

Agency Contact Information

Kids Lives Matter Licensed Home Childcare Agency
Phone: 647-321-1914
Email: Klmkiddoscare@gmail.com
Website: www.kidslivesmatter.ca

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

Intake Questionnaire

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

INTAKE QUESTIONNAIRE

For Infants, Toddlers, and Preschool

Please complete and give to your Provider on your first day

Child Information

Child's Full Name *

Date of Birth *

Does your child have siblings?

Yes No

Has your child had any illnesses or been hospitalized?

Yes No

How many adults participate in your child's regular care on a typical day?

Name all adults that participate in regular care, at what time and how:

SLEEPING

Has your child shown any sleeping problems?

Yes No

How long does he/she sleep at night?

What is his/her sleeping pattern?

Do you have any special ways of helping them to go to sleep?

Yes No

Does your child usually cry when going to sleep?

Yes No

Does he/she cry when they wake up?

Yes No

Does he/she sleep in their own bed/crib?

Yes No

Does he/she sleep in their own room?

Yes No

Does he/she sleep with any special toys/blankets?

Yes No

FEEDING/EATING

Has your child had any feeding/eating problems?

Yes No

What are his/her favourite foods?

What foods does he/she dislike?

Are there any allergies or sensitivities to particular foods?

Yes No

Are these allergies Anaphylactic?

Yes No

Please inform your agency if your child has Anaphylactic Allergy

INFANTS ONLY (12 months and under)

Is your infant Breastfed?

Yes No

Bottle fed?

Yes No

Do you give your infant a vitamin/mineral supplement regularly?

Yes No

Which foods is your infant eating?

How does your infant eat or drink at home?

In your arms High chair Other

Specific feeding instructions (times and amounts):

OTHER

How does your child react to new situations (separation, strangers)?

What strategies do you use to comfort your child if upset or frightened?

How does your child behave when ill?

If your child has a sibling at home, how do they interact or play together?

Does your child play quietly in the house?

Yes No

Special concerns regarding Discipline:

Special concerns regarding Toilet Training:

Restrictions for media (TV, computer, gaming)?

What kind of experiences do you expect home child care to provide for your child?

Additional comments:

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

COVID-19 Attestation

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

Parent/Guardian Attestation

COVID-19 Procedures

Child's Name *

Provider's Name *

To manage the risk of COVID-19 spread within our childcare homes, Kids Lives Matter is adhering to all Public Health guidelines and procedures in addition to our already existing policies and procedures under the Child Care and Early Years Act. In addition to the policies and procedures set out in our Parent Handbook and until further notice, we are also putting additional measures in place that parents must agree to for their child to be in care.

Licensed childcare agencies cannot permit any child with symptoms of COVID-19 to attend care.

Each Day:

You should screen your child and yourself before taking your child to the Provider's home, using the Ontario COVID-19 Online Screening Tool (https://covid-19.ontario.ca/school-screening/) for your daily screening. If you do not have online access, please ask your agency for a paper copy of the online screening questions.
The tool provides guidance on if a child can or cannot attend care based on several factors. Our exclusion policy follows the advice of the current Ontario COVID-19 screening Tool.

If your child experiences any signs and symptoms of COVID-19 while in care, the Provider will contact you or one of your emergency contacts to pick the child up immediately. Your child will be separated from the other children in care until you arrive. Children with symptoms may be excluded from care after the onset of symptoms for an isolation period as directed by the current guidelines. This exclusion may also apply to children that are exposed to a presumed or confirmed case of COVID-19.

I, (print name) *

I agree to the following:

I have read and understood the information above

I understand the risk of illness associated with placing my children in a home childcare program

I agree to the daily screening requirements

Misrepresentation or falsifying screening answers may result in the termination of my childcare placement

I will not administer any medication to my child that may mask the symptoms of illness (such as Tylenol or Advil) prior to dropping my child off for care

Parent Signature (Type Full Name) *

Date *

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

Emergency Form

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

EMERGENCY FORM

Please give to your Provider on your child's first day

Child's Name *

Date of Birth *

Child's Address *

Home Phone

Parent/Guardian Information

Parent 1 Name *

Cell # *

Work #

Parent 2 Name

Cell #

Work #

Emergency Contacts (persons to contact/release child to if parents unavailable)

Name

Daytime #

Evening #

Name

Daytime #

Evening #

Name

Daytime #

Evening #

Medical History and Information

Known allergies, health, medical, or food restrictions?

Yes No

History of communicable diseases:

None Chicken Pox Rubella Mumps Measles Whooping Cough Scarlett Fever

Parental Consent

If at any time due to accident, sudden illness, or emergency, medical treatment is required, this may be given, including anesthetic (if necessary) by a private physician or hospital.

Additional specific instructions:

Parent Signature (Type Full Name) *

Date *

Child Start Date *

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

Non-Prescription Consent

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

NON-PRESCRIPTION CONSENT FORM

(For sunscreen, creams, ointments and other non-prescription products applied to skin)

Child's Name *

Date of Birth *

Provider's Name *

IMPORTANT: All products below must be:

Supplied by the parent in the original container/box with the child's name and date on it
Stored inaccessible to the children
Recorded in the logbook each time it is used (date, time, amount)

Items	Instructions to parents
Sunscreen (Cannot use on infants under 6 months)	N/A When outdoors exposed to sun Apply when:
Moisturizing Skin Lotion	N/A Apply when skin is dry Apply when:
Lip Balm	N/A Apply when lips are dry Apply when:
Insect Repellent	N/A Apply if/when exposed to insects Apply when:
Hand Sanitizer (Not permitted for children under 2 years)	N/A Apply when:
Diaper Cream	N/A Apply when diapering area has a rash Apply when:
Other

Other specific instructions or restrictions:

Signature of Parent/Guardian (Type Full Name) *

Date *

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

Medical Consent Card

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

MEDICAL CONSENT CARD

Providers carry this with them at all times for each child in care

Instructions: Parent completes and signs. Print and cut out. Bring to Provider on Day 1 of care.

MEDICAL CONSENT CARD

Child's Name *

Date of Birth *

Health Card #

Expiry

Address

Dr's Name

Dr's Phone #

Note special considerations (allergies, medications, conditions):

N/A

Parent 1 Cell *

Parent 2 Cell

Alternate Contacts if parents can't be reached:

If, at any time, due to such circumstances as accident, sudden illness or emergency, medical treatment is required, this may be given, including anaesthetic, if necessary, by physician or hospital.

Parent Name *

Date *

Parent Signature (Type Full Name) *

*This authority may be terminated on written notice by undersigned

Agency Phone Number

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

Sleeping Arrangements

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

Alternate Sleeping Arrangements

As a licensed child care agency, Kids Lives Matter must ensure that all requirements of the Child Care and Early Years Act are met. According to the Act, children under 18 months of age must nap in a crib or playpen. Children over 18 months of age must sleep on a cot.

In order to allow alternate arrangements, the following consent must be completed and signed by the child's parent or guardian.

Parent's Name *

Provider's Name *

Child's Name *

Child's Age *

I give consent for my child to nap/sleep on:

A cot

A playpen

(Height and weight of child needs to be in accordance with the recommendations of the manufacturer)

A mat

(Only if agency has approval)

Other:

Restrictions/special instructions:

Signature of Parent/Guardian (Type Full Name) *

Date *

Note: Agency signature will be added upon review and approval of this form.

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

Photo & Video Consent

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

PHOTO AND VIDEO CONSENT FORM

Permission for photographs and video recordings

Child's Name *

Date of Birth *

Provider's Name *

From time to time, photographs and/or video recordings may be taken of children during childcare activities. These images may be used for various purposes as outlined below. Please read each option carefully and indicate your consent preferences.

I give permission for my child to be photographed or videotaped for the following purposes:

Documentation and PortfolioPhotos/videos may be used to document your child's learning and development, and may be included in your child's portfolio or daily activity reports shared with parents/guardians.

Display in Childcare SettingPhotos/videos may be displayed on walls, bulletin boards, or in common areas within the childcare home to celebrate children's activities and achievements.

Social Media and WebsitePhotos/videos may be posted on the agency's or provider's social media accounts (Facebook, Instagram, etc.) or website for promotional and marketing purposes. Your child's full name will not be used without additional permission.

Marketing and Promotional MaterialsPhotos/videos may be used in brochures, flyers, newsletters, advertisements, or other promotional materials for the childcare agency.

Sharing with Other ParentsPhotos/videos that include my child may be shared with other parents in the childcare program (e.g., group photos from events or activities).

Media and PressPhotos/videos may be shared with local media or press for news stories, articles, or features about the childcare program.

Special Instructions or Restrictions:

If you have any specific concerns or restrictions regarding photography or video recording of your child, please specify below:

Important Information:

This consent remains in effect for the duration of your child's enrollment unless you revoke it in writing.
You may withdraw or modify your consent at any time by providing written notice to the agency.
Children's full names will not be used in public materials without additional specific consent.
All photos and videos will be taken and used in a respectful manner appropriate for children.

Parent/Guardian Name (Print) *

Signature (Type Full Name) *

Date *

Legal Notice: By signing this form, I acknowledge that I have read and understand the uses of photographs and videos as described above, and I consent to the uses I have selected. I understand that I may revoke this consent at any time in writing.

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

Outdoor Play Plan

Kids Lives Matter

Licensed Home Child Care Agency

📞 647-321-1914 | Klmkiddoscare@gmail.com

OUTDOOR PLAY PLAN

Parent consent and preferences for outdoor activities

Child's Name *

Date of Birth *

Provider's Name *

Outdoor play is an essential part of child development, providing opportunities for physical activity, exploration, and connection with nature. This form outlines the outdoor activities your child may participate in and requests your consent and preferences.

Outdoor Activities

I give permission for my child to participate in the following outdoor activities:

Backyard Play

Playing in the provider's fenced backyard with age-appropriate equipment and toys

Neighborhood Walks

Walks around the neighborhood in stroller or on foot (with proper supervision)

Local Parks and Playgrounds

Visits to nearby parks and playgrounds within walking distance or short drive

Nature Walks and Exploration

Walking trails, nature exploration, and outdoor learning activities

Water Play (Supervised)

Sprinklers, water tables, or wading pools (always with direct supervision)

Winter Activities

Snow play, sledding (age-appropriate), and winter outdoor exploration

Community Outings

Library visits, community events, farmers markets, etc.

Weather Conditions

My child may participate in outdoor play in the following weather conditions:

Sunny/Warm weather Light rain (with appropriate clothing) Cold weather (with appropriate clothing) Snowy conditions

Temperature restrictions or preferences:

Safety Requirements

Sun Protection:

I will provide sunscreen (SPF 30+) for my childProvider may apply their own sunscreen (see Non-Prescription Consent Form)

Bug Spray:

I will provide insect repellent for my childProvider may apply their own insect repellent (see Non-Prescription Consent Form)

Hat/Sun Protection Clothing:

Rain Gear:

Winter Gear:

Transportation

Stroller UseMy child may be transported in a stroller for walks and outings

Wagon UseMy child may be transported in a wagon for walks and outings

Special Instructions or Restrictions

Please note any specific outdoor play restrictions or preferences:

Important Notes:

Children will be supervised at all times during outdoor activities
Outdoor play time is weather dependent and at the provider's discretion for safety
Parents will be notified of any outings beyond the immediate neighborhood
Appropriate clothing should be provided daily based on weather forecasts
This consent remains in effect unless modified in writing by the parent

Parent/Guardian Name (Print) *

Signature (Type Full Name) *

Date *

Kids Lives Matter Licensed Home Child Care Agency • Ontario, Canada

647-321-1914 | Klmkiddoscare@gmail.com | www.kidslivesmatter.ca

Submit Your Full Intake Package

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