Family Connections - We Help Connect Parents and Childcare Providers

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Childcare 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 childcare providers will be available within two working days. The information provided is for referral purposes only. MT Childcare 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(s):	First: Last:
	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 #:

Email Address:

* 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 folowing information for all children needing childcare:

	* 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?

Childcare Center (13 or more children) School Age Program

Family Childcare (3 - 6 children) Group Home Childcare (3 - 6 children/adult)

Preschool (1/2 day, usually not licensed)
Summer Program

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 childcare to be walking distance from school

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

1.

2.

3.

4.

* Who is providing your current care?

No current care Before/After school program

Family member Preschool

Friend Head Start

Nanny
Family/group childcare

Childcare center LUP/LUI

* Do you receive childcare payment assistance?

No Assistance

Best Beginnings Scholarship

FAIM

Respite

Tribal Block Grant

Would you like information regarding childcare 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

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

If yes, see the following childcare checklists:

Would you like any Parenting information? Yes No

Would you like any Child Development information? Yes No

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

Mailed to my address (Only if outside Great Falls).

Emailed 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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Licensing and registration does not guarantee a quality program. All parents are encouraged to visit programs prior to enrolling a child.
This project is funded (in part) under a contract with the MT Department of Health and Human Services. The statements herein do not necessarily reflect the opinion of the Department.