CHILD CARE NEED FORM

Please copy form into a WORD document and email to skreep@childcarepartnerships.org

~or~

Drop off or mail to: Child Care Partnerships, 901 North Benton Ave., Helena, MT 59601

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 2 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.

Today’s Date: Is this the first time you have received a referral? Yes No

Parent(s) Name(s): Starting Date Care is Needed:

Street Address: City: Zip:

Mailing Address: City: Zip:

Home phone: Work/other:

Employer: Spouse/Partner’s Employer:

Care is requested: Near home Near work Near parent school:

Near child’s school No preference Valley East Helena Other:

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

Name Name Name

Date of Birth_____________ M F Date of Birth_____________ M F Date of Birth_____________ M F

Age:___ Age:____ Age:____

Mon: ______ to ______ Mon: ______ to ______ Mon: ______ to ______

Tue: ______ to _______ Tue ______ to ______ Tue ______ to ______

Wed: ______ to ______ Wed ______ to ______ Wed ______ to ______

Thurs: ______ to ______ Thurs ______ to ______ Thurs ______ to ______

Fri: ______ to ______ Fri ______ to ______ Fri ______ to ______

Sat: ______ to ______ Sat ______ to ______ Sat ______ to ______

Sun: ______ to ______ Sun ______ to ______ Sun ______ to ______

Do you receive childcare payment assistance? YES NO If no, indicate:

Household size______ Monthly gross income____________

Care Needed:

Part-time Full-time No preference

Year Schedule:

Full year School year Summer only

Extra Care Service

Drop in care 24-hour care Before school care

After school Rotating schedule ___ Temp./emergency care

What type of care are you looking for?

Child Care Center Family Child Care Preschool

(13 or more children) (3-6 children) (1/2 day, usually not licensed)

School Age Program Group Home Child Care Summer Program

(6-12 children)

Do you have any needs and/or preferences regarding the environment?

Provider will toilet train Offers field trips Wheelchair accessible

No pets at facility Outdoor activities Uses a structured Curriculum (Preschool)

Non-smoking facility Outdoor play equipment

No TV _ Does not use vehicle transportation

Do you need a provider who speaks a language other than English? YES NO

If yes, what language?

Does your child have any special needs that may require accommodation

ADHD/ADD Autism Catheter

Down Syndrome Diabetes Hearing impaired

Vision impairment Seizures Cerebral Palsy

Tube feeding Asthma Developmentally delayed

Fetal alcohol syndrome/effect Emotional/Mental health

Please select the geographical area that most pertains to you (for search purposes only)

1. Capitol, Upper Eastside 2. Central

3. Westside 4. Valley

5. East Helena 6. Townsend/Lincoln

7. Mt. City, Clancy 8. Boulder, Whitehall

9. Wolf Creek, Craig

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 though they may not have an immediate opening.

Would you like your referral listing to include providers with waiting lists? YES NO

Transportation Needs (Only if Required)

I require transportation from provider I rely on public transportation

I need child care to be walking distance from school

If you require transportation from your child care provider, please specify need.

To/from Kindergarten Before and after school To/from child’s home

To/from child’s activities Transportation for family

What schools do your children attend (or) what schools do you live nearby?

Helena:

___ Broadwater ___ Bryant ___ Central ___ Four Georgians ___ Hawthorne

___ Jefferson ___Jim Darcy ___Kessler ___ Rossiter ___Smith ___Warren

Others:

___ Clancy ___ Montana City ___ Eastgate ___ Radley ___ Lincoln ___ Other: ______________

Who is providing your current care?

Family/group child care Child care center Head Start

Family member Friend Nanny

No current care Preschool LUP/LUI

Before/after school program

Applicant’s Relation to child(ren):

Employment status:

Employed Seeking employment

At home Student

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 learn about our services?

Employer Friend/relative Previous user

Newspaper, radio, TV Brochure/poster Community agency

Phone book-yellow pages ___ Tribal program Internet/website

Child Care Provider

What is your reason for seeking child care?

Work Looking for work School/training

Respite care Child’s need Parent’s need

Current care closing Tribal program Current cost too high

Unhappy with quality of current care

OPTIONAL

Child Health

___ Did Not Want Info On ___ Child is Fully Immunized ___ Send Immunization Info

___ Has Health Care Provider for Child ___ Has Health Insurance for Child ___ No Insurance for Child

___ Referred to Hotline – 877-KIDS-NOW ___ Referred to Mental Health Consultation

___ Referred to Nursing Consultation ___ Referred to Special Needs Consultation

___ Referred to CHIP Program

Would you like: parenting information (classes, etc) child development information (pamphlets, etc.)

YES___________ NO____________

Do you speak Spanish/Hispanic/Latino?

___ No, not Spanish, Hispanic, or Latino speaking ___ Yes, Mexican, Mexican American, Chicano

___ Yes, Puerto Rican ___Yes, Cuban ___ Yes, Other ______________________

What is your race?

___ White ___Black/African American ___American Indian or Alaska Native ________________

___ Asian Indian ___Native Hawaiian ___ Chinese ___Filipino ___ Japanese

___ Other Asian ___ Guamanian or Chamorro ___ Samoan ___Vietnamese

___ Other Pacific Islander __________________ ___ Other Race _________________________

What is your ancestry or ethnic origin? _________________________________________________

(for example: Italian, Jamaican, African Am, Cambodian, Norwegian, Haitian, Korean)

Do you speak another language at home? Yes No If yes: ________________________________

Thank you for your time!

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For Office Use Only

Referral Date CCP Received: Form Processed By: ________

Fee: $__________ Appointment Date: ________________ With: ________________ Time: _______ AM/ PM

Consumer Education Information:

__ Choosing Quality Childcare

__ Childcare checklist

__ 10 Ways to Improve Your Child’s Care

__ Six Ways to be an Advocate for your Child Care

__ Child Development Information

__ Parenting Classes

__ Licensing information on Centers, Group and Family regulations

Comments:

Revised 11/01/04skr