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During the COVID-19 Pandemic, community providers are offering temporary, emergency child care during the emergency period for essential, medical, and emergency personnel as identified in Governor Bullock's Stay at Home Direction, 2-20-2020 and 3-20-2020. The following application invites programs who are providing temporary emergency child care to apply for support.
Section 1: Program Information

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* 1. Program Name (Fiscal Agent):

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* 2. Phone Number: 

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* 3. Key Contact Name: 

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* 4. Physical Address:

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* 5. Mailing Address:

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* 6. Email Address:

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* 7. Days/Hours of operation:

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* 8. Date you started to provide care:

Date

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* 9. Number of children you expect to care for:

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* 10. Youngest and oldest age of children you will provide care to (youngest/oldest):

Section 2: Background Checks

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* 11. Have background checks been completed for staff? 

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* 12. If background checks have not been completed, would you like DPHHS to conduct name-based background checks for your staff? If yes, please submit an “Emergency COVID-19 Release of Information” for each individual. To receive this form, please contact Child Care Licensing at 406-444-2012, or by email: childcarelicensing@mt.gov

Section 3: Statewide Resources

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* 13. Please select all that apply (someone will contact you at the email address you provided above):

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* 14. Have you received a grant or loan to assist with COVID-19 related losses from any local, state, or federal government or a private fund? (Check all that apply)

Section 4: Financial Support Request (only complete this section if you are requesting financial support)
DPHHS estimates approximately 20 programs across the state will be awarded. In the event that we receive a greater number of requests, the Department will evaluate each application for content, need, and community demand. 

Categories of one-time only funding are as follows:
  • Programs who serve less than 10 children per day are eligible to apply for up to $23,000
  • Programs who serve between 11 and 24 children per day are eligible to apply for up to $55,000
  • Programs who serve greater than 24 children per day are eligible to apply for up to $90,000

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* 15. Total amount requested:

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* 16. How will you use the grant funds? Please select all that apply:

Please fax a completed W9 Form to 406-444-2547, attention: Sarah Adams
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