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Child Care Needs Form

In order to find the best match for you and your children’s needs, please complete the following information. A referral list of registered or licensed child care providers will be available within two working days. The information provided is for referral purposes only. MT Child Care Resource & Referral agencies do not warrant the information concerning any provider, nor do we license, endorse, or recommend any particular provider. Only you can determine whether the quality of care is appropriate for your child by thorough screenings and visits with the provider prior to care being provided.


Note: Required fields are marked with an *

* Today's Date:

* Is this the first time you have recieved a referral? Yes     No



* Parent Name: First: Last:



* Street Address:     * City:   * State:    * Zip:



* Mailing Address:   * City:   * State:     *  Zip:

* ... or
Check here if Street Address and Mailing Address are the same.


* Home Phone:   Work/Other #:   Cell #:   Fax #:

Email Address:


* Are You Employed?

Yes
No
Student

Employer:

Type of Employment:

Spouse/Partner's
Employer:


Type of Employment:

Would you like an Internet user account to search for child care online?
If yes, please visit this page and click on the "Register" button.  This will allow you to create your own account with a personalized password to perform a basic search for child cares.

Yes
No


* Care is Requested: (check one)

Near Home
Near Work (Give location below)
Near Child's School (List school below)
Near Parent's School (List school below)
No Preference
Other (Please explain below)

Details:


Please complete the following information for all children needing child care:

  * Child's Name * Date of Birth * Day(s) Needed *Time(s) Needed
1.
2.
3.
4.

* Starting Date Care is Needed:


Other Scheduling Needs: (check all that apply)

Full-time (30+ hrs/week) Rotating Schedule
Part-time (less than 30 hrs) Summer only
Full-year care 24-hour Care
School year only After-school Care
Drop-in Care Temp/emergency care
Before-school Care  

* What type of facility are you looking for? (check all that apply)

Child Care Center (13 or more children) School Age Program
(CCC) Tribal Licensed Program Unlicensed School Age Program
Family Child Care (3-6 children)
Group Home Child Care (7-12 children)
Preschool Program
Unlicensed Sick Care
Unlicensed Summer Program
Unlicensed Drop-in Care

Do you have any needs/preferences regarding environment? (check all that apply)

Provider will toilet train No pets at facility
Non-smoking facility No vehicle transportation
Offers field trips Outdoor activities
Outdoor play equipment Preschool Program
Wheelchair accessible Uses a structured curriculum
No TV Summer Program

Do you need a provider who speaks a language other than English?

Yes
No

If yes, what language?


If you are looking for a provider with special needs experience, please specify need:


Often providers do not have frequent vacancies but maintain a waiting list. We encourage parents to look at all facilities that meet their criteria even thought they may not have an immediate opening.

Do you want your referral listing to include providers with waiting lists? Yes     No


Transportation Needs (Only if Required)

None

I require transportation from provider

Please specify need: (check all that apply)
To/from Kindergarten
To/from child’s activities
To/from child’s home
Before and after School
Transportation for family
I rely on public transportation
I need child care to be walking distance from school
I need family transportation

* What school(s) do/does your child(ren) attend?

1.
2.
3.
4.

* Who is providing your current care? (check all that apply)

No current care Before/After school program
Family member Preschool
Friend Head Start
Nanny
Family/group child care
Child Care center LUP/LUI

* Do you receive child care payment assistance?

No Assistance
Best Beginnings Scholarship (Family Connections)
TANF
Respite
Tribal Block Grant
Tribal TANF

Would you like information regarding child care payment assistance? Yes     No


* What is your family size? (Number of adults and children in your household)

Single Adult in Household
Two or More Adults in Household

* How did you hear about our services?(check all that apply)

Employer Media: newspaper, radio, TV
Phone Book/Yellow Pages Child care provider
Friend/relative Brochure/poster
Tribal program Previous User
Community agency Internet/website
Unknown  

* What is your reason for seeking child care? (check all that apply)

Work Respite care
Current care closing Current cost too high
Looking for work Child's needs
Asked to leave School/training
Parent's needs Unhappy with quality of current care

Would you like a personal consultation on selecting quality child care? Yes     No


If you would like any parenting or child development information, please specify:


I would like to have my referral list: (check one)

Mailed to my address.
Emailed to me (Note: We cannot send email to AOL accounts).
Faxed to me.
I will pick it up on this date and time:

Please double-check your entries for accuracy, make any needed changes, then click "Submit Form". If you need to completely start over, click "Clear Form" (Be advised: this will clear everything entered on the form).



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