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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?

    Child Care Service Information

    Transportation - Choose all that apply.

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


    EnglishNative AmericanSpanishFrenchGermanAmerican Sign LanguageOther

    Hours of Operation

    Do you offer extended hours?

    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


    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


    BreakfastMorning SnackLunchAfternoon SnackDinnerEvening SnackChild Care Food ProgramOPI Afterschool Snack Program


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

    Best Beginnings Child Care Scholarship


    Best Beginnings STARS to Quality


    Policies - Choose all that apply

    Separate sick area for children while waiting for parent to pick up
    Charges for absent days
    Closed for vacations 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

    Special Skills

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

    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?

    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