Child Care Needs Form Request

Child Care Needs Form

Please fill out this form and we'll match your child care needs with area providers.  Complete information helps us match your needs with available facilities, for example close to home or work, or after school care close to school.  Some information is for statistical purposes only, to help us understand child care supply and demand throughout the state.

Contact Information

Your Name*
Home Address
Street Address*
Address Line 2
City*
State*
Zip Code*
County*
Is your MAILING address different than your HOME address?*
Mailing Address
Mailing Address Line 2
Mailing City
Mailing State
Mailing Zip Code
Telephone*
Alternative Telephone
Email*

Tell us a little bit about yourself....

Have you received a list of child cares in the state of Montana before?*
Are you employed?*
Do you receive child care payment assistance?*
Do you consider your family to be homeless?*
Are you currently in the military?*

Tell us a little bit about your children and the care requests you have.

Providing this information helps us to better match you with child care providers.

Starting date that child care is needed*
Number of Children*
Child Care Days and Hours Needs*
Fill out ALL the fields below fro each child requiring care.  Missing information prohibits us from being able to provide you a list of child cares.  If your hours and days are varied, please list all potential days and hours care may be needed.  For example, list the earliest time that you would ever work and teh latest your would ever work.

Please use the format hh:mm followed by am or pm for the start and end times.  
 Example:1:00 pm
CHILD'S NAME(1)*
BIRTHDATE(1)*
CHILD CARE HOURS NEEDED(1)
CHILD'S NAME(2)
BIRTHDATE(2)
CHILD CARE HOURS NEEDED(2)
CHILD'S NAME(3)
BIRTHDATE(3)
CHILD CARE HOURS NEEDED(3)
CHILD'S NAME(4)
BIRTHDATE(4)
CHILD CARE HOURS NEEDED(4)
CHILD'S NAME(5)
BIRTHDATE(5)
CHILD CARE HOURS NEEDED(5)
CHILD'S NAME(6)
BIRTHDATE(6)
CHILD CARE HOURS NEEDED(6)
CHILD'S NAME(7)
BIRTHDATE(7)
CHILD CARE HOURS NEEDED(7)
CHILD'S NAME(8)
BIRTHDATE(8)
CHILD CARE HOURS NEEDED(8)

What kind of child care provider would best meet your needs?

What kind of schedule should the provider be able to accommodate? Check all that apply*
What kind of facility would you be most comfortable with? Check all that apply*
Do you have any needs/preferences regarding environment? Check all that apply*
Do you need a provider who speaks a language other than English?*
If you are looking for a child care provider with special needs experience, please specify need.
Transportation needs (if required)*
Would you like to include providers that have waiting lists?

Just a couple more questions and you're done!

Answering these questions helps us to tailor our services to the needs of the community and better understand who is currently looking for child care.

How did you hear about our services?*
What is your reason for seeking child care? Check all that apply*

How would you like your referral list delivered to you?

Please have my list of matching child care providers:*
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