COVID-19 Temporary Emergency Child Care Support Application

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

Question Title

* 1. Program Name (Fiscal Agent):

Question Title

* 2. Phone Number:

Question Title

* 3. Key Contact Name:

Question Title

* 4. Physical Address:

Street Address:

City:

State:

Zip Code:

Question Title

* 5. Mailing Address:

Street Address/PO Box:

City:

State:

Zip Code:

Question Title

* 6. Email Address:

Question Title

* 7. Days/Hours of operation:

Question Title

* 8. Date you started to provide care:

Please select a date:

Date

Question Title

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

Question Title

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

Section 2: Background Checks

Question Title

* 11. Have background checks been completed for staff?

Yes

Question Title

* 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

Yes

Section 3: Statewide Resources

Question Title

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

I am interested in participating in the Child and Adult Care Food Program

I am interested in receiving support for my staff with professional development

I am interested in additional program support

Question Title

* 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)

SBA Payroll Protection Program (PPP)

SBA Economic Injury Disaster Loan Program (EIDL)

Private Loan

Private Grant

Public Grant

No other assistance received

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

Question Title

* 15. Total amount requested:

Question Title

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

Personnel costs

Cleaning and sanitation

Operating Expenses

Other

Please explain how you will use the grant funds for each category selected above:

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