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Provider Information Form

  • Complete this form if you are due for an Annual Update, have expired information in the referral database, or are a new provider just registering for the referral program.
  • This is not the correct form if you are an existing provider needing to update rates, vacancies, or make a general change to your profile.

You must be authored to report this information


YesNo
By clicking yes, I understand I will not receive my referral correspondence by mail and if my email address changes, I will notify Family Connections immediately



YesNo
Clicking yes means that the following information may be emailed to families searching for child care: first name, business name, address, city/state/zip, facility type, phone number, hours/days, ages served, map, rates, and full/part time status.


YesNo



Yes


Capacity & Age Range



Please enter a value between 0 and 500.

Please enter a value between 0 and 500.

Please enter a value between 0 and 500.

Service Information



YesNo

YesNo

YesNo


YesNo


Close to public transportation Walking distance to school On a school bus route


English Native American Spanish French German Hmong Russian Sign Language Other


YesNo

Shifts



Full-time childrenPart-time childrenBoth full and part-time children

Full YearSchool Year OnlySummer Only


Drop in Temporary/emergency care Before School After School
Rotating Shifts 24 Hour Care


YesNo


Transportation Fee Charge above state rate Activity/Registry Fee Meal Fee Multi-child discount Advanced payment required Weekly flat rate only Monthly flat rate only Minimum daily charge

Population Information


Attributes



Will toilet train
Offers field trips
Wheelchair accessible
No pets at facility
No TV
Has outdoor activities
Structured Curriculum
Summer program
Outdoor play equipment
Non-smoking facility (even when closed)
Preschool program
Does not use vehicle transportation


Breakfast
Morning snack
Lunch
Afternoon snack
Dinner
Evening snack
Accommodates special meal request
Child Care Food Program participant
OPI Afterschool Snack Program Participant


Separate sick area for children while waiting for parent to pick up
Charges for absent days
Closed for vacation and sick days (closes facility when on vacation or sick
Uses substitutes when absent (keeps facility open by using substitutes)
Charges for holidays when facility is closed


Music
Drama
Art
Sports
Other


CPR Current within 2 years
First Aid Training
Liability Insurance
Health-Related Degree


ADHD/ADD
Autism
Catheter
Downs syndrome
Diabetes
Hearing impaired
Vision impaired
Seizures
Cerebral Palsy
Tube Feeding
Asthma
Developmentally delayed
Fetal alcohol effect/syndrome
Emotional/mental health
MD Medical disability
Food allergies
Cystic Fibrosis
Have the experience to care for children with these needs.


8-15 hours
16-38 hours
39-67 hours
68+ hours
After school specialized
Pre-school specialized
SOS/BEST graduate
Infant-Toddler specialized
Based on your registration cycle.


Under 1 Year
1-3 Years
4-9 Years
10-20 Years
21+ Years
Have the experience to care for children with these needs.


High school education
AA, child related
AA, other
Some college, child related
Some college, other
CDA
Bachelors, child related
Bachelors, other
Masters, child related
Masters, other


MTAEYC
MTCCA


Extended License
Level 1 on career path
Level 2 on career path
Level 3 on career path
Level 4 on career path
Level 5 on career path
Level 6 on career path


Mini Grant
Merit Pay
Provider Grant


Diaper Service
Art Lessons
Gymnastic Lessons
Music Lessons
Skiing Lessons
Backup Care Network
Swimming Lessons


Non-residential
Faith based
Workplace based
Mobile home
School
Located in church
Intergenerational
Franchise
Duplex
Apartment
Residential house


Brochure/Poster/Rack Card
Child Care Resource & Referral Agency
Friend/Relative
Child Care Provider
Community Agency
Newspaper/Radio/TV
Internet
Quality Assurance Division
MTCCA
Other



I affirm, authorize, understand and acknowledge.

I hereby affirm that the statements in the Provider Information Form are accurate, complete, and true to the best of my knowledge. I hereby authorize Family Connections Montana to share the information I have provided with families seeking child care and for statistical purposes. I agree to provide additional documentation concerning the Provider Information Form to Family Connections Montana at their request. I understand that Family Connections Montana reserves the right to remove my name and/or facility from the referral database. I understand that it is my responsibility to keep my provider information updated with Family Connections Montana and to complete this form on an annual basis unless otherwise requested.