Child Care Needs Form In order to find the best match for you and your children’s needs, please complete the following information. The information provided is for referral purposes only. Montana Child Care Resource & Referral agencies and the Best Beginnings Child Care Referral Program do not guarantee 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. Date* Date Format: MM slash DD slash YYYY Have you ever received a referral listing in Montana?*YesNoContact InformationYour Name* First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Is your MAILING address different than your HOME address? Yes, I have a different mailing address Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Primary Phone Number*Secondary Phone NumberFax NumberEmail* Do you live in an...*If other please specify, for example, hotel, motel, camp ground, shelter.ApartmentHouseMobile HomeWhat best describes you?*Select only the primary one.At-home ParentChild and Family Services DivisionEmployedFoster ParentSeeking EmploymentServing the MilitaryStudentDo you currently receive the Best Beginnings Child Care Scholarship?*YesNoIf yes, what program are you participating in?*CPSNon-TANFTANFTribal TANFUnknownDo you have a preference on a child care provider’s location?*Zip CodeCityNearest Elementary SchoolCountyPlease specify which zip code, city, elementary school, or county for the location search.*Starting date that child care is needed* Date Format: MM slash DD slash YYYY Child Care Days and Hours Needs*Fill out the ALL the fields below for 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 you would ever work and the latest you would ever work. Click to add another entry or to delete the entry. Child's NameGenderBirthdateChild Care Hours Needed Other scheduling needs.*Check all that apply. After School Before School Full-time (More than 30 hours/week) Part-time (Less than 30 hours/week) Rotating Schedule Summer Only What Type of Care are you looking for?*Check all that apply. Child Care Center (13 or more children) Group Child Care (7-12 children) Family Child Care (3-6 children) Preschool program School age program (CCC) Tribal Licensed Program Do you have any needs/preferences regarding environment?*Check all that apply English as a Second Language No pets at facility No TV Non-smoking facility Offers field trips Outdoor play equipment/activities Provider will toilet train STARS to Quality Provider Summer program Uses a structured curriculum Wheelchair accessible If you are looking for a provider with special needs experience, please specify need.Do you want your referral listing to include providers with waiting lists?*YesNoTransportation Needs (Only if Required)I need child care to be walking distance from school.I need family transportation.I rely on public transportation.I require transportation to and from school.What is your relationship to the child(ren)? Please select one.*MotherFatherGrandparentGuardianCase ManagerHow did you learn about child care referral services?*Please check all that apply. Brochure/Rack Card Child care provider Community agency Employer Friend/relative Internet/Website Media: Newspaper, radio, TV Phone book-Yellow pages Previous user Regional CCR&R Agency State of Montana agency Tribal program What is your reason for seeking child care?*Check all that apply. Work Current care closing Looking for work Asked to change child care providers Parent's needs Respite care Child's needs School/training Current 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.YesNoHow would you like to receive the consumer education information?*EmailMailPick-upI do not want Consumer EducationPlease 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 me at the address listed on this formEmailed to me at the email address listed on this formFaxed to the number listed on this formI will pick it up from my regional CCR&R agencyPlease indicate when you are picking up your referral list.* Date Format: MM slash DD slash YYYY This section is available for you to leave additional information for the Referral Specialist.