Home - Montana State Legislature
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The Big Sky Country
MONTANA STATE LEGISLATURE
2015 CHILD CARE PROVIDER FORM
Facility Name____________________________________________________________________________________
Last Name_____________________________________First Name________________________________________
Other Contact (s)_________________________________________________________________________________
Primary Contact Phone #_________________________Other Phone #______________________________________
Email Address__________________________________Website___________________________________________
Provider Physical Address__________________________________________________________________________
Provider Mailing Address__________________________________________________________________________
Type of Provider_________________________________________________________________________________
Please describe your facility setting___________________________________________________________________
Please list all licenses, certifications, & qualifications____________________________________________________
_______________________________________________________________________________________________
License Information:
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If licensed, please list PV number_________________________Total licensed capacity_________________________
Total number of vacancies with dates_________________________________________________________________
_______________________________________________________________________________________________
Please describe your child care experience_____________________________________________________________
_______________________________________________________________________________________________
Are you CPR certified?____________________________________________________________________________
Have you had a background check (Child Protective Services or Criminal)?___________________________________
_______________________________________________________________________________________________
Hours of operation________________________________________________________________________________
Do you offer extended hours or weekend care?__________________________________________________________
Rates___________________________________________________________________________________________
Do you provide meals?____________________________________________________________________________
Do you provide any transportation?___________________________________________________________________
Mailing Address: Email Address: Questions:
Lindsey Grovom lgrovom@ (406)444-4819
Legislative Services Division
PO Box 200400
Helena, MT 59620-0400
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