Provider Information Form Name*FirstLast Business/Facility Name* License/Provider Number (PV#)* Address* Zip* Do you have a different mailing address?YesNo City* County* State* Address (mailing) Zip (mailing) City (mailing) County (mailing) State (mailing) Primary Phone Number* Area Code - Phone Number Email Address Fax Phone Number Area Code - Phone Number Website Please indicate which type of child care your facility is. *Child Care CenterFamily Child CareGroup Child CareTribal-Licensed ProgramSchool Age ProgramPreschool ProgramHead Start Child Ages ServedYearsMonthsWeeksYoungest AgeOldest Age Capacity/EnrollmentDesired CapacityCurrent EnfollmentInfant (0-23 months)Toddler (2 years old)Preschool (3-5 years)School Age (6 years old and older) Full-Time VacanciesFull-Time VacancyDate Vacancy BeginsInfant (0-23 months)Toddler (2 years old)Preschool (3-5 years)School Age (6 years old and older) Part-Time VacanciesPart-Time VacancyDate Vacancy BeginsInfant (0-23 months)Toddler (2 years old)Preschool (3-5 years)School Age (6 years old and older) Do you maintain a waiting list when you do not have vacancies?*YesNo Please list public schools served: 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. Do you speak any of the following languages?*EnglishNative AmericanSpanishFrenchGermanAmerican Sign LanguageOther Please list hours of operation.* If you offer extended hours, please specify. Please list the Holidays the your facility is opened. Is your facility opened...*Full yearSchool year onlySummer only Do you accept....*Full-time children onlyPart-time children onlyBoth full-time and part-time children Please check all that apply for type of care provided.Drop-inRotating ShiftsTemporary/Emergency24-hour careBefore schoolAfter School Do you charge for any of the following?Transportation FeeActivity FeeMinimum Daily ChargeCharge above the state rateMeal FeeRegistration FeeAdvanced payment require Do you offer a multi-child discount?YesNo What kind of environment do you offer at your facility? Check all that apply.Will toilet trainPreschool ProgramSTARS to Quality ProgramSummer ProgramOffer field tripsTV is not watchedEnglish as second languageWheelchair accessibleNo pets at facilityStructured curriculumHas outdoor activities/equipment What meals are provided?BreakfastMorning SnackLunchAfternoon SnackDinnerEvening SnackChild Care Food ProgramOPI Afterschool Snack Program What is the philosophy you use?Faith basedMontessoriWaldorfReggio EmiliaParent Cooperative (Facility is run by Parent Board)Other Do you participate in the Best Beginnings Child Care Scholarship?YesNo Do you participate in the STARS to Quality program?YesNo What STARS to Quality level is your child care facility on? Please check all that apply.Seperate sick area for children while waiting for parent to pick upCharges for absent daysClosed 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 Does your child care facility provide any of the following special skills?MusicDramaArtSportsOther What special needs experience does your child care facility have?ADHS/ADDAutismCatheterDowns SyndromeDiabetesHearing ImpariedVision ImpariedSeizuresCerebral PalsyTube FeedingAsthmaDevelopmentally DelayedFetal Alcohol SyndromEmotional/Mental HealthMedical DisabilityFood AllergiesCystic Fibrosis Please select the numbers of years of education for the Director of your child care facility.Under 1 year1-3 years4-9 years10-20 years21 years or more Please list the educational background for the Director of your child care facility. Are you a current member of the following professional organizations?MTAEYCMTCCA What best describes your child care facility?Non-residential homeWorkplace basedMobile HomesPublic/Private SchoolLocated in churchDuplexApartmentIntergernerationalResidential HomeFranchise Hear AboutEmployerFriend/relativePrevious userMedia-newspaper, radio, TVBrochure/Rack CardCommunity agencyTribal ProgramPhone book - Yellow PagesChild Care ProviderRegional CCR&R AgencyInternet/websiteState Montana agency 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 on child care referrals.) I grant perrmission for my child care facility to be added to both the referral database and online referral database.*I agree I understand the preferred method of contact is email. If you entered a email address above, the email will be used to communicate with you.*I agree 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 agree I hereby affirm that the statements in the Provider Information Form are accurate, complete and true to the best of my knowledge.*I agree I agree to provide additional documentation concerning the Provider Information Form to the regional CCR&R agency at their request.*I agree 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 agree Please enter your full name as signature on this form.*Print Please enter the letters/numbers: SubmitReset