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Test Contact Form

    Contact Information


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

    State*

    State



    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)Fmily 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.

    This section is available for you to leave additional information for the Referral Specialist.