Thank you for your interest in Eden Brook Care. If you wish to submit your application to Eden Brook Care to find a placement with a family, please complete this form and click the "submit" button at the bottom {or you can print this page and fax it back to (647) 439.1548}.  There is a non-refundable application deposit fee of $250.00 to register with us. Correspondence with your prospective family would be forwarded through Eden Brook Care until both parties agreed to disclosure of personal contact information.  Only non-identifying information will be released to the Family. 

Please fill out all applicable fields in the form below, and send by clicking on the "Submit" button when completed. 

Summary Profile

Name:

Date of Birth:

Education:

Experience:

Personal:

Personal Information

Full Name:

Surname (Last name)    
First name (Given name) 
Middle initial (s) 

Home Address:

Telephone No:

e.Mail Address:

Age:

Date of Birth: (DD/MM/YYYY)

I am a citizen of:

-- CITIZEN -- Australia Austria BERMUDA Canada China Czech Republic France Germany Gibraltar Greece Hungary Italy Japan Lithuania Malaysia Mexico Netherlands New Zealand Peru Philippines Saudi Arabia Singapore Slovak Republic South Africa Spain Switzerland USSR (former) United Kingdom United States chile Other: other:

Where do you presently reside?

-- RESIDENCE -- Australia Austria BERMUDA Canada China Czech Republic France Germany Gibraltar Greece Hungary Italy Japan Lithuania Malaysia Mexico Netherlands New Zealand Peru Philippines Saudi Arabia Singapore Slovak Republic South Africa Spain Switzerland USSR (former) United Kingdom United States chile Other: other:

Country of origin:

-- ORIGIN -- Australia Austria BERMUDA Canada China Czech Republic France Germany Gibraltar Greece Hungary Italy Japan Lithuania Malaysia Mexico Netherlands New Zealand Peru Philippines Saudi Arabia Singapore Slovak Republic South Africa Spain Switzerland USSR (former) United Kingdom United States chile Other: other:

Height:

Weight:

Religion: 

Marital Status: 

-- Select One -- Single Married Separated Divorced Widowed

Spouse's Name:

Surname (Last name)     
First name (Given name) 
Middle initial(s) 

Do you have any children? 

Yes No    If "yes", please provide details:

Do you have any  brothers or sisters? 

Yes No    If "yes", please provide details: 

Education

1. Name of Institution  
List any Diploma, Certificate, Degree obtained

From:     To:

2. Name of Institution  
List any Diploma, Certificate, Degree obtained

From:     To:

What languages do you speak?

English French  Other_____________  

Would you like to further your education in any way while in Canada?

Yes No

If yes, please indicate what you would like to do:

Employment History

Please give a brief description of your work history Include all child care experience and any other positions held within the last five (5) years. Please list your child care experience first.

• Name of Family/Organization

• Position/Occupation 

• Ages of children cared

• Responsibilities

• Held From/To 

• Reason for Leaving 

Type of Care Provided

Date available for employment: (include year)

Full or Part Time?

-- Employment -- fulltime employment parttime employment

Expected salary (range, monthly net):

Accommodation Type?

-- Accommodation -- live-in live out

Length of commitment?

-- Length of Commitment -- six months one year longer

Do you have a valid driver's license?            Yes No

How long have you been Driving?                

Do you have a car?                                  Yes No

Do you have a valid passport?

Yes No    

Have you ever traveled abroad?

Yes No   If yes, please provide details: 
(Country visited, purpose of visit, length of stay, reason for leaving)

Number of children you would like to care for: 

Which age group would you prefer to work with?
Babies Toddlers 2 to 5 Older children

Are you willing and/or qualified to care for children with special needs (physical, mental or handicapped) Yes No

As a Caregivers, you will be required to perform some or all of the following 
duties with respect to the child(ren) in the family, please select all that you are willing to assume:

About You 

Do you have training in: 
a) First Aid? Yes No
b) CPR? Yes No 
If so, please provide a copy of your certificate (s). 

Do you swim? Yes No
How well? Strong Moderate Weak Afraid of water

Do you like pets? Yes No
If yes, what kind?
All Dogs Cats Birds Other

Do you smoke? Yes No
If yes, how frequently?
Occasionally Regularly Heavily

Are you allergic to anything? e.g. (food, medication, plants, etc.) Yes No
If yes, give details:

What are your hobbies and/or interest?

Person to be contacted in case of an emergency:

Person to be contacted in case of an emergency: 

Please indicate below how you first learned about Eden Brook Care:

Other Information

Is there any information that we have not requested but which you think we should know? 

Method of Payment