Child Care Needs Form Request THIS IS NOT THE APPLICATION FOR THE CHILD CARE SCHOLARSHIP THIS IS ONLY FOR CHILD CARE REFERRALS Date Your Name*FirstLastPhysical Address Street Address* City* State* Zip Code* County* Is your MAILING address different than your HOME address?*NoYes, I have a different mailing address Mailing Address Mailing City Mailing State Mailing Zip Code Primary Phone Number* Area Code - Phone Number Secondary Phone Number Area Code - Phone Number Fax Phone Number Area Code - Phone Number Email Address* Have you received a list of child cares in the state of Montana before?*YesNo Do you live in an...*ApartmentHouseMobile HomeOther What best describes you? Select only the primary one.*EmployedServing in the MilitarySeeking EmploymentChild and Family Services DivisionStudentFoster ParentAt-home Parent Do you currently receive the Best beginnings Child Care Scholarship?*YesNo If above question is yes, then what program are you participating in?*TANFNon-TANFCPSTribal TANFUnknown Do you have a preference on the child care provider's location? Based on this selection you will need to enter the location in the next box.No PreferenceZip CodeCityElementary SchoolCounty Please enter the Zip Code: Please enter the City: Please enter the Elementary School: Please enter the County: Starting date that child care is needed* Number of Children*Select value12345678 CHILD'S NAME(1)* Gender(1)FemaleMale BIRTHDATE(1)* CHILD CARE HOURS NEEDED(1)Start TimeEnd TimeMondayTuesdayWednesdayThursdayFridaySaturday CHILD'S NAME(2) Gender(2)FemaleMale BIRTHDATE(2) CHILD CARE HOURS NEEDED(2)Start TimeEnd TimeMondayTuesdayWednesdayThursdayFridaySaturday CHILD'S NAME(3) Gender(3)FemaleMale BIRTHDATE(3) CHILD CARE HOURS NEEDED(3)Start TimeEnd TimeMondayTuesdayWednesdayThursdayFridaySaturday CHILD'S NAME(4) Gender(4)FemaleMale BIRTHDATE(4) CHILD CARE HOURS NEEDED(4)Start TimeEnd TimeMondayTuesdayWednesdayThursdayFridaySaturday CHILD'S NAME(5) Gender(5)FemaleMale BIRTHDATE(5) CHILD CARE HOURS NEEDED(5)Start TimeEnd TimeMondayTuesdayWednesdayThursdayFridaySaturday CHILD'S NAME(6) Gender(6)FemaleMale BIRTHDATE(6) CHILD CARE HOURS NEEDED(6)Start TimeEnd TimeMondayTuesdayWednesdayThursdayFridaySaturday CHILD'S NAME(7) Gender(7)FemaleMale BIRTHDATE(7) CHILD CARE HOURS NEEDED(7)Start TimeEnd TimeMondayTuesdayWednesdayThursdayFridaySaturday CHILD'S NAME(8) Gender(8)FemaleMale BIRTHDATE(8) CHILD CARE HOURS NEEDED(8)Start TimeEnd TimeMondayTuesdayWednesdayThursdayFridaySaturday What kind of schedule should the provider be able to accommodate? Check all that apply*Full-time (30 + hrs./week)Part-time (less than 30 hrs./week)Before SchoolAfter SchoolRotating/Shifting scheduleSummer only Do you speak any of the following languages? Multiple choices can be made.EnglishGermanNative AmericanAmerican Sign languageSpanishFrenchOther What kind of facility would you be most comfortable with? Check all that apply*Child Care Center (13 or more children)Group Child Care (7 - 12 children)Family Child Care (3 - 6 children)Preschool programSchool age program(CCC) Tribal Licensed ProgramHead Start Do you have any needs/preferences regarding environment? Check all that apply*Provider will toilet trainSummer programSTARS to Quality ProviderOffers field tripsNo pets at facilityPreschool ProgramWheelchair accessibleOutdoor activities/equipmentEnglish as Second LanguageUses a structured curriculumNo TV Would you like to include providers that have waiting lists?YesNo If you are looking for a child care provider with special needs experience, please specify need. Transportation needs (if required)*No special transportation needsI rely on public transportationI need family transportationI need child care to be walking distance from schoolI require transportation to and from school What is your relationship to the child(ren)? Please select one.MotherFatherGrandparentGuardianCase ManagerOther How did you hear about our services?*EmployerBrochure/Rack CardChild care providerFriend, relative or colleagueCommunity agencyRegional CCR&R AgencyPrevious userTribal programInternet/websiteMedia: newspaper, radio, TVPhone book-yellow pagesState of Montana Agency What is your reason for seeking child care? Check all that apply*WorkChild's needsLooking for workParent's needsSchool/trainingCurrent care closingRespite careAsked to change child care providersCurrent environment did not meet child's needs Would you like a personal consultation on selecting quality child care? If yes, please call and schedule an appointment time to speak with a Referral Specialist.YesNo How would you like to receive the consumer education information?MailEmailPick-upI do not want Consumer Education Please have my list of matching child care providers: A child care referral will be available within 1-2 business days and will be provided to you in the preferred way indicated below:*Mailed to the address on this form.Emailed to the email address on this form.Ready for pick it up from my regional CCR&R agencyFaxed to the fax number on this form. The below section is available for you to leave additional information for the Referral Specialist.Print Word Verification:SubmitReset