First Name

Last Name

Preferred Name

Email Address

Phone Number

Dayhome Address

Neighbourhood

Years of Experience

Certification level

Current Status: Current Status: New Educator (brand new to the world of dayhomes) Current Private Educator (operating a dayhome without a license) Previously Licensed Educator (coming back to dayhome after absence or had a license and then decided to operate privately) Currently Licensed Educator (changing Agencies)

Additional languages spoken/written, please indicate level of fluency

Ages of children current in care

Maximum number of children you intend to care for

Please provide a description of your Dayhome Program

Please provide a description of your programs typical rhythm/routine

Your Dayhome offers Your Dayhome offers Full-time Part-time Before/After School Overnight

How would you describe your approach to caregiving and learning?

What does “quality care” mean in your practice?

What interests you in partnering with a family dayhome agency?

Please share any relevant education or certifications

Current First Aid & CPR status (expiry date)

Food Safety Training

Any additional professional development

What areas are you interested in for further learning or support?

Please indicate you agree to the following Please indicate you agree to the following I am willing to operate in alignment with Hummingbird Family Dayhome Agency policies and procedures I understand Alberta Child Care Licensing requirements apply to my program I am open to consultation, monitoring, and ongoing communication I understand that Agency partnership is subject to review and approval

How do (or will) you communicate with families?

Are you open to community referrals and support connections when appropriate? Are you open to community referrals and support connections when appropriate? Yes No

Have you worked with community agencies or other external support before? (optional) Have you worked with community agencies or other external support before? (optional) Yes No

Is there anything you would like us to know about your program or circumstances?

Do you have any questions about agency partnership?

Acknowledgement Acknowledgement I understand that submitting this form is an expression of interest and does not guarantee agency partnership. I acknowledge that Hummingbird Family Dayhome Agency will review this information to determine alignment and next steps.