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Child Care Needs Form

In order to find the best match for you and your children’s needs, please complete the following information. Referral requests will be processed and disbursed within 1-5 business days depending on the specific requests and referral volume. The information provided is for referral purposes only. Child Care Referral Program does not warrant the information concerning any provider, nor do we license, endorse, or recommend any particular provider. Only you can determine whether the quality of care is appropriate for your child by thorough screenings and visits with the provider prior to care being provided.

Contact Information


State*

Is the mailing address different than the one listed above?
Yes



Tell us a little bit about yourself...


Have you ever received a list of child cares in the state of Montana before?*
YesNo

Are you employed?*
YesSeeking EmploymentStudentAt home

Do you receive child care payment assistance?*
No AssistanceNon-TANF Best Beginnings Child Care ScholarshipTANF Best Beginnings Child Care ScholarshipTribal Block GrantTribal TANF

Tell us a little bit about your children and the care requests you have.


Providing this information helps us to better match you with child care providers.


Child Care Days and Hours Needed*
Fill out the ALL the fields below for each child requiring care. Missing information prohibits us from being able to provide you a list of child cares. If your hours and days are varied, please list all potential days and hours care may be needed. For example, list the earliest time you would ever work and the latest you would ever work.


Need Care? Start Time End Time
MON NoYes
TUE NoYes
WED NoYes
THU NoYes
FRI NoYes
SAT NoYes
SUN NoYes

We are able to search for child cares based on specific location requests. Please check a preference if desired.
(Please note this can greatly restrict your options and we will not include it if it hinders the ability to get you a list of child cares.)
Zip CodeCityNearest Elementary SchoolCounty

What kind of child care provider would best meet your needs?



Full-time (30+ hrs./week)Part-time (less than 30 hrs./week)Before/After schoolRotating/Shifting scheduleSummer only
What kind of facility would you be most comfortable with?* (Check all the apply.)
Child Care Center (13 or more children)Group Child Care (7-12 children)Family Child Care (3-6 children)Preschool programSchool age program(CCC) Tribal Licensed Program
Do you have any needs/preferences regarding environment?* (Check all the apply.)
Provider will toilet trainNon-smoking facilityOffers field tripsOutdoor play equipment/activitiesWheelchair accessibleNo TVNo pets at facilityUses a structured curriculumSummer program
Do you need a provider who speaks a language other than English?*
YesNo


Transportation needs (if required)*
No special transportation needsI rely on public transportationI need family transportationI need child care to be walking distance from schoolI require transportation to and from school
Would you like your list to include providers that have waiting lists?
YesNo

Just a couple more questions and you're done!

Answering these questions helps us to tailor our services to the needs of the community and better understand who is currently looking for child care.


How did you hear about our services?
EmployerPhone book/yellow pagesFriend, relative or colleagueTribal programCommunity agencyLocal Child Care Resource and Referral AgencyMedia: Newspaper, radio, TVInternet search engineChild care providerBrochure/posterPrevious userUnknown
What is your reason for seeking child care?*
WorkCurrent care closingLooking for workAsked to leaveParent's needsRespite careCurrent cost too highChild's needsSchool/trainingUnhappy with quality of current care

How would you like your referral list delivered to you?


Please have my list of matching child care providers:*
If you will be picking up your referral in person, please call ahead to be sure it's ready to pick up when you arrive.
Mailed to my addressEmailed to meFaxed to meI will pick it up at my local child care resource and referral agency