Childcare Disqualification Declaration Form
Please complete this form to declare any circumstances that may disqualify you from providing childcare. All responses must be accurate and complete.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current or Most Recent Childcare Role
*
How many years of experience do you have in childcare?
*
Are you currently subject to any of the following disqualifying circumstances?
*
Conviction for offenses against children
Being barred from working with children
Ongoing investigations regarding child safety
Disciplinary action related to childcare duties
None of the above
If you selected any disqualifying circumstances above, please provide details.
Have you previously had a childcare registration revoked or refused?
*
Yes
No
Please provide the date of this declaration
*
 -
Month
 -
Day
Year
Date
Submit Declaration
Should be Empty: