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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




Child Age Served


Youngest Age Served:

Years Months Weeks

Oldest Age Served:

Years Months Weeks

Capacity & Vacancies


Infant (0-23 months)

Toddler(2 years old)

Preschool (3-5 years old)

School Age (6 years old and older)

Waiting List


Do you maintain a waiting list when you do not have vacancies?
NoYes

Child Care Service Information


Transportation - Choose all that apply.


Transportation provided for children to/from the family’s home.
YesNo
Transportation provided for children to and from activities.
YesNo
Child care facility is located near public transportation.
YesNo
Transportation provided for children to and from school.
YesNo
Transportation provided for children to and from bus stop.
YesNo
Child care facility is located within walking distance to school.
YesNo

Languages



EnglishNative AmericanSpanishFrenchGermanAmerican Sign LanguageOther

Hours of Operation


Do you offer extended hours?
YesNo

Is your facility open (check only one)
Full yearSchool year onlySummer only

Full-time and Part-time Attendance


Do you accept
Full-time childrenPart-time childrenBoth full-time and part-time children

Type of Child Care


Please check all that apply for type of care provided
Drop-inTemporary/EmergencyBefore SchoolAfter SchoolRotating Shifts24-hour care

Rates


Do you charge for any of the following
Transportation FeeCharge above the state rateRegistration FeeActivity FeeMeal FeeAdvanced payment requiredMinimum Daily Charge

Do you offer any of the following discounts
Multi-child discount

Attributes (Environment)



Will toilet trainOffer field tripsWheelchair accessibleStructured curriculumPreschool ProgramTV is not watchedNo pets at facilityHas outdoor activities/equipmentSTARS to Quality ProviderEnglish as a Second LanguageSummer Program

Meals



BreakfastMorning SnackLunchAfternoon SnackDinnerEvening SnackChild Care Food ProgramOPI Afterschool Snack Program

Philosophy



Faith basedMontessoriWaldorfReggio EmiliaParent Cooperative (Facility is run by Parent Board.)Other

Best Beginnings Child Care Scholarship



YesNo

Best Beginnings STARS to Quality



YesNo

Policies - Choose all that apply


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

Special Skills


Does your child care facility provide any of the following special skills?
MusicDramaArtSportsOther

Special Needs


What special needs experience does your child care facility have?
ADHD/ADDAutismCatheterDowns SyndromeDiabetesHearing ImpairedVision ImpairedSeizuresCerebral PalsyTube FeedingAsthmaDevelopmentally DelayedFetal Alcohol SyndromeEmotional/Mental HealthMedical DisabilityFood AllergiesCystic Fibrosis

Professional Child Care Experience and Education


Please select a number of ears for the Director of your child care facility.
Under 1 year1-3 years4-9 years10-20 years21 years or plus

Professional Organization


Are you a current member of the following professional organization?
MTAEYCMTCCA

Facility Setting


What best describes your child care facility?
Non-residential homeWorkplace basedMobile HomesPublic/Private SchoolLocated in churchDuplexApartmentIntergenerationalResidential HomeFranchise

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

Provider Statement


In your own words what do you want parents to know about your facility. (This is the exact text that will be available
to parents on child care referrals.)

Please initial the following statements:


I grant permission for my child care facility to be added to both the referral data base and online referral data base.
I AgreeI Disagree

I understand the preferred method of contact is email. If you indicate you have email address, this is what will be used to communicate with you.
I AgreeI Disagree

The following information will appear on the child care facility profile: First Name, Business Name, Address, City/State/Zip, Facility Type, Phone Number, Hours/Days, Ages Served, Map to Street, Rates, and Full/Part Time.
I AgreeI Disagree

I hereby affirm that the statements in the Provider Information Form are accurate, complete and true to the best of my knowledge.
I AgreeI Disagree

I agree to provide additional documentation concerning the Provider Information Form to the regional CCR&R agency at their request.
I AgreeI Disagree

I understand that the regional CCR&R agency reserves the right to remove my name and/or facility from the referral database.
I AgreeI Disagree

I understand that it is my responsibility to keep my provider information updated with the regional CCR&R agency and to complete this form on an annual basis unless otherwise requested.
I AgreeI Disagree