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: __ Regulated/Licensed __ Registered __ Exempt 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@mt.gov (406)444-4819 Legislative Services Division PO Box 200400 Helena, MT 59620-0400