Child Care Referral Program

By providing information in this form, the child care facility will be added to the child care referral services for families in Montana.  

Please contact referrals@cccmontana.org with any questions.  

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* 1. Contact Information

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* 2. Fax Number

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* 3. License/Provider Number (PV)

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* 4. Mailing Address (if different from above)

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* 5. Website or Facebook Page

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* 6. Please indicate which type of child care your facility is. 

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* 7. Infants Served (0-23 months) *Check all that apply

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* 8. Toddlers Served (2 years) *Check all that apply

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* 9. Preschool Served (3-5 years) *Check all that apply

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* 10. School-Aged Served (6+) *Check all that apply

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* 11. Do you maintain a waiting list?

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* 12. What school district is your program in?

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* 13. Does your program provide any type of transportation?

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* 14. Is your program located near public transportation?

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* 15. Do you speak any of the following languages? *Select all that apply

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* 16. If "Other", please specify.  

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* 17. What are your facility's hours of operation? 

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* 18. Do you provide weekend care?

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* 19. Do you provide evening care?

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* 20. When is your facility open?

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* 21. What type of enrollment do you accept?

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* 22. What type of care do you provide? *Select all that apply

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* 23. Do you charge for any of the following? *Select all that apply

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* 24. Do you provide any of the following? *Select all that apply

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* 25. Do you provide meals? *Check all that apply

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* 26. What philosophy do you use?

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* 27. Do you accept the Best Beginnings Child Care Scholarship?

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* 28. Do you participate in the STARS to Quality program?

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* 29. Are you interested in receiving information on the following programs?  *Check all that apply

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* 30. What Special Needs experience does your child care facility have? *Select all that apply

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* 31. If "Other", please specify.  

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* 32. 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 child care referrals.)

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* 33. I grant permission for my child care facility to be added to both the referral data base and the online referral data base. 

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* 34. I understand that the preferred method of contact is email.  If I have indicated an email address, this is what will be used to communicate with me.  

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* 35. The following information will appear on my 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. 

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* 36. I hereby affirm that the statements in this Provider Information Form (PIF) are accurate, complete, and true to the best of my knowledge.

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* 37. I agree to provide additional documentation concerning the Provider Information Form (PIF) to the regional CCR&R agency at their request.

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* 38. I understand that the regional CCR&R agency reserves the right to remove my name and/or facility from the referral database. 

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* 39. 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.

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* 40. Electronic Signature (please type the first and last name of the authorized signer)

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* 41. Date (MM/DD/YYYY)

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