Provider Intake Package

Complete all required forms before your first placement

Kids Lives Matter

Licensed Home Child Care Agency

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

PROVIDER-AGENCY AGREEMENT

Kids Lives Matter Licensed Home Child Care Agency

This agreement is entered into between Kids Lives Matter Licensed Home Child Care Agency (the "Agency") and the home child care provider named below (the "Provider"), effective upon signing.

Provider Full Name *

Address *

Phone *

Agreement Start Date *

Provider Responsibilities

Provide safe, nurturing, developmentally appropriate care.Maintain a clean, safe, child-proofed home environment.Follow all guidelines and policies set by Kids Lives Matter.Maintain current First Aid/CPR and required certifications.Communicate professionally with parents and agency staff.Report any concerns, incidents, or injuries immediately.Maintain strict confidentiality regarding families in care.Participate in required training and professional development.Provide at least 2 weeks notice before ending care.

Agency Responsibilities

Match the Provider with suitable families based on location and availability.
Provide ongoing support, resources, and guidance to the Provider.
Handle all invoicing and payment coordination with families.
Ensure all families are screened and agree to the Agency's standards.

Fees & Payment

Provider Rate (per day/week)

Payment Schedule

Acknowledgement & Signatures

By signing below, both parties agree to the terms and responsibilities outlined in this agreement.

Provider Signature (Type Full Name) *

Date *

Agency Representative *

Date *

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

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

Kids Lives Matter

Licensed Home Child Care Agency

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

PROVIDER-AGENCY AGREEMENT

Kids Lives Matter Licensed Home Child Care Agency

This agreement is entered into between Kids Lives Matter Licensed Home Child Care Agency (the "Agency") and the home child care provider named below (the "Provider"), effective upon signing.

Provider Full Name *

Address *

Phone *

Agreement Start Date *

Provider Responsibilities

Agency Responsibilities

Match the Provider with suitable families based on location and availability.
Provide ongoing support, resources, and guidance to the Provider.
Handle all invoicing and payment coordination with families.
Ensure all families are screened and agree to the Agency's standards.

Fees & Payment

Provider Rate (per day/week)

Payment Schedule

Acknowledgement & Signatures

By signing below, both parties agree to the terms and responsibilities outlined in this agreement.

Provider Signature (Type Full Name) *

Date *

Agency Representative *

Date *

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

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

Kids Lives Matter

Licensed Home Child Care Agency

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

PROVIDER INFORMATION FORM

Please complete all sections accurately

Personal Information

Full Legal Name *

Date of Birth *

Home Address *

Phone Number *

Email Address *

Location / Area Served *

Availability *

Experience & Qualifications

Years of Child Care Experience *

Age Groups Comfortable With

Certifications (First Aid, CPR, ECE, etc.)

Previous Employers / Experience Summary

Languages & Special Skills

Languages Spoken

Special Skills / Activities Offered

Declaration

I confirm that the information provided above is accurate and complete to the best of my knowledge.

Signature (Type Full Name) *

Date *

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

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

Kids Lives Matter

Licensed Home Child Care Agency

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

PROVIDER REFERENCES FORM

Please provide three professional or personal references (not family members)

Reference 1

Full Name *

Relationship *

Phone Number *

Years Known

Reference 2

Full Name *

Relationship *

Phone Number *

Years Known

Reference 3

Full Name *

Relationship *

Phone Number *

Years Known

Additional Comments

I authorize Kids Lives Matter to contact the references listed above to verify my background and experience.

Signature (Type Full Name) *

Date *

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

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

Kids Lives Matter

Licensed Home Child Care Agency

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

BACKGROUND CHECK CONSENT FORM

Required for all providers working with children

Under the Child Care and Early Years Act, 2014 (CCEYA), Kids Lives Matter is required to conduct background checks on all individuals providing child care. This includes a Vulnerable Sector Check through local police services, used solely to ensure the safety of children in our care.

Provider Details

Full Legal Name *

Date of Birth *

Current Address *

Phone Number *

Social Insurance Number (SIN)

Previous Names (if applicable)

Previous Legal Name

Reason for Name Change

Consent & Acknowledgement

I consent to Kids Lives Matter conducting a Vulnerable Sector Background Check through the Ottawa Police Service or applicable local police service.I understand that I am responsible for obtaining the police check and providing a copy to the agency.I understand that a criminal record does not automatically disqualify me, but will be reviewed on a case-by-case basis.I confirm that all information provided is true and accurate. Any false statements may result in termination of my agreement.

Signature (Type Full Name) *

Date *

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

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

Kids Lives Matter

Licensed Home Child Care Agency

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

HOME SAFETY CHECKLIST

Provider must complete and submit prior to caring for children

Provider Name *

Home Address *

General Home Safety

Smoke detectors installed on every levelCarbon monoxide detector workingFire extinguisher accessible & not expiredEmergency evacuation plan postedAll exits are clear and accessibleStairways have secure railings and are well-lit

Child-Proofing

Electrical outlets covered with safety plugsCabinets with hazardous materials lockedSharp corners and edges coveredSafety gates at top and bottom of stairsWindow guards on upper-floor windowsHeavy furniture anchored to walls

Kitchen Safety

Cleaning products stored out of reachKnives and sharp utensils stored safelyStove knob covers in placeNo dangling appliance cords

Bathroom Safety

Medications locked and out of reachNon-slip mats in tub/shower and floorHot water set to 49°C (120°F) or belowToilet lid locks installed (for infants/toddlers)

Outdoor / Play Area

Outdoor play area is fenced and securePlay equipment is in good repairSandbox covered when not in useYard free of toxic plantsPool/water features are fenced and gated

Pets

Pets are vaccinated and child-friendlyPet food kept away from childrenPet separated from children when unsupervised

I certify that the above safety measures are in place at my home and that I will maintain these standards throughout my time as a provider with Kids Lives Matter.

Signature (Type Full Name) *

Date *

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

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

Kids Lives Matter

Licensed Home Child Care Agency

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

OFFENCE DECLARATION FORM

Required under the Child Care and Early Years Act, 2014 (Ontario)

Under the CCEYA, all individuals providing child care in Ontario must declare any offences. This declaration must be completed honestly and updated immediately if circumstances change. Failure to disclose is a serious violation.

Provider Details

Full Legal Name *

Date of Birth *

Current Address *

Phone Number *

Email Address *

Offence Declaration

1. Have you ever been convicted of a criminal offence for which you have not received a pardon/record suspension?

Yes No

2. Have you ever been found guilty of an offence under the Child and Family Services Act or the CCEYA?

Yes No

3. Are you currently under investigation or facing charges related to abuse, neglect, or mistreatment of a child?

Yes No

4. Have you ever had a child care licence revoked, suspended, or refused by any regulatory body?

Yes No

5. Have you ever been named in a substantiated child protection report as a person who has harmed a child?

Yes No

If you answered "Yes" — provide full details (dates, nature, outcome):

Ongoing Obligation to Disclose

I understand I must immediately notify Kids Lives Matter if I am charged with or convicted of any offence after this date. Failure to disclose may result in immediate termination.

I acknowledge my ongoing obligation to disclose any future offences or charges immediately.

Declaration & Signature

I declare that the information provided is true, complete, and accurate. Making a false declaration is a serious offence and may result in legal consequences.

Signature (Type Full Name) *

Date *

Witness / Agency Representative

Date

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

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

Kids Lives Matter

Licensed Home Child Care Agency

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

NOTICE OF COLLECTION OF PERSONAL INFORMATION

Kids Lives Matter Licensed Home Child Care Agency

This notice is provided in accordance with the Child Care and Early Years Act, 2014 (CCEYA), the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA), and the Freedom of Information and Protection of Privacy Act (FIPPA).

Authority for Collection

Kids Lives Matter Licensed Home Child Care Agency is authorized to collect personal information under the Child Care and Early Years Act, 2014, specifically for the purpose of licensing, supervising, and administering home child care services in the Province of Ontario.

Purpose of Collection

The personal information collected through this intake package will be used for the following purposes:

To assess your suitability as a home child care provider.
To verify qualifications, certifications, and references.
To conduct required Vulnerable Sector background checks.
To administer your Provider Agreement with the Agency.
To communicate with you regarding placements, training, and agency matters.
To comply with regulatory reporting requirements under the CCEYA.
To maintain accurate records as required by Ontario legislation.

Disclosure of Information

Your personal information will be kept strictly confidential and will not be disclosed to any third party without your consent, except where required or permitted by law, including disclosure to regulatory bodies, licensing authorities, or law enforcement agencies as required under the CCEYA or other applicable legislation.

Retention of Records

Personal information collected will be retained for the duration of your engagement with Kids Lives Matter and for the period required by applicable law. Records will be securely disposed of when no longer required.

Your Rights

You have the right to access and request corrections to your personal information held by this Agency. To make such a request or if you have questions about the collection, use, or disclosure of your personal information, please contact us at:

Kids Lives Matter Licensed Home Child Care Agency

Email: Klmkiddoscare@gmail.com | Phone: 647-321-1914

✍ Acknowledgement — To Be Signed

I have read and understand this Notice of Collection of Personal Information. I consent to the collection, use, and disclosure of my personal information as described above for the purposes of my provider application and agreement with Kids Lives Matter.

Provider Full Name *

Date *

Signature (Type Full Name) *

Witness / Agency Representative

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

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

Instructions

Complete all forms before your first child care placement
Print, sign, and submit all forms to the agency
Obtain your Vulnerable Sector police check and provide a copy to Kids Lives Matter
Keep copies of all signed forms for your records
Update forms as your information changes