Provider Information Form

Business Address*

Mailing Address (if different)

Type of Provider*
Child Care CenterFamily Child CareGroup Child CarePre-School ProgramSchool-Age ProgramTribal Licensed ProgramHead Start

Child Age Served

Capacity & Vacancies

Infant (0-23 months)

Toddler(2 years old)

Preschool (3-5 years old)

School Age (6 years old and older)

Waiting List

Child Care Service Information

Please list public schools served:

Transportation - Choose all that apply.

Languages

Do you speak any of the following languages? Multiple choices can be made.
EnglishNative AmericanSpanishFrenchGermanAmerican Sign LanguageOther

Hours of Operation

Please list your facility's hours of operation:

Do you offer extended hours?
YesNo

Please list the Holidays your facility is open:

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)

What kind of environment do you offer at your facility? Check all that apply.
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

What meals are provided?
BreakfastMorning SnackLunchAfternoon SnackDinnerEvening SnackChild Care Food ProgramOPI Afterschool Snack Program

Philosophy

What is the philosophy you use?
Faith basedMontessoriWaldorfReggio EmiliaParent Cooperative (Facility is run by Parent Board.)Other

Best Beginnings Child Care Scholarship

Do you accept the Best Beginning Child Care Scholarship?
YesNo

Best Beginnings STARS to Quality

Do you participate in the STARS to Quality program?
YesNo
If yes, what STARS level is your child care facility on??

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