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

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

First Name*

Last Name*

Home Address*

City*

State*

Zip*

County*

Mailing Address (if different)

City

State

Zip

County

Telephone*

Alternate Telephone

Email*

Fax

Do you live in an...
ApartmentHouseMobile HomeOther

If other please specify, for example, hotel, motel, camp ground, shelter

What best describes you? Select only the primary one
EmployedSeeking EmploymentStudentAt-home ParentServing in the MilitaryChild and Family Services DivisionFoster Parent

Is your primary language: EnglishNative AmericanSpanishFrenchGermanAmerican Sign LanguageOther

Do you currently receive the Best Beginnings Child Care Scholarship?
YesNo

If yes, what program are you participating in?
TANFNon-TANFCPSTribal TANFUnknown

Do you have a preference on a child care provider's location.

Please complete the following information for all children needing child care

Date that child care is needed:

Name (First,Last)	Gender	Date of Birth	Days Care is Needed	Hours Care is Needed

Other Scheduling Needs: Check all that apply:

Full-time (more than 30 hours/week)Part-time (Less than 30 hours/week)Before SchoolAfter SchoolRotating ScheduleSummer Only

What Type of Care are you looking for?

Child Care Center (13 or more children)Family Child Care (3-6 children)Group Child Care (7-12 children)School Age ProgramPreschool Program(CCC) Tribal Licensed Program

Do you have any needs/preferences regarding the child care provider's environment?

Providers will toilet trainOffers field tripsWheelchair accessibleUses a structured curriculumNo TVNo pets at facilityOutdoor activities/equipmentSTARS to Quality ProviderEnglish as a Second Languagepreschool programsummer program

Special Needs

If you are looking for a provider with special needs experience, please specify:

Waiting List

Do you want your referral listing to include providers with waiting lists?
YesNo

Transportation Needs (Only if required)

I need child care to be walking distance from school.I require transportation to and from school.I rely on public transportation.I need family transportation.

What is your relationship to the child(ren)? Please select one.

MotherFatherGrandparentGuardianCase ManagerOther

If other, please specify:

How did you learn about child care referral services? Please check all that apply.

EmployerFriend/relativePrevious userMedia-newspaper, radio, TVBrochure/Rack CardCommunity agencyTribal ProgramPhone book-Yellow PagesChild Care ProviderRegional CCR&R AgencyInternet/websiteState of Montana agency

What is your reason for seeking child care?

WorkLooking for workSchool/trainingRespite CareChild's needsParent's needCurrent care closingAsked to change child providersCurrent environment did not meet child's needs

Personal Consultation

Would you like a personal consultation on selecting quality child care?
YesNo
If yes, please call and schedule an appointment time to speak with a Referral Specialist

Consumer Education

How would you like to receive the consumer education information?
MailEmailPick-upI do not want Consumer Education

I would like to have my child care referral list: (Please select one)

A child care referral will be available within 1-2 business days and will be provided to you in the preferred way indicated below.
I will pick it up from my regional CCR&R agency.Mailed to me at the address listed on the form.Faxed to the number listed on this form.Emailed to me at the email address listed on the form.