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Childcare for All
Childcare for Essential Workers is open to children in grades K-6.
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Full Name
*
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Spouse Name
Your answer
Children's Names (separated by commas)
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Your answer
Children's Ages (separated by commas). Note: Childcare is open to kids in grades K-6.
*
Your answer
Address
*
Your answer
City & State
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Your answer
Home Phone
Your answer
Cell Phone
*
Your answer
Email
*
Your answer
Total Number of People in Your Household
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Your answer
Please provide your total annual household income
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Your answer
I certify that the information provided here is accurate and complete to the best of my knowledge and that I have provided all necessary information.
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Digital Signature
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Your answer
Date
*
MM
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DD
/
YYYY
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