Last Name, First Name (Parent needing child care) *
Your answer
Phone Number (cell phone preferred)
Your answer
Child's Last Name, First Name
Your answer
Child's age *
Where is your place of employment?
Your answer
What is your position (job title)?
Your answer
I attest that I am the custodial parent of the above named child and that no other child care is available. (Documentation of custodial relationship is required.) *
I attest that I am a healthcare worker or first responder (police, fire, EMS, corrections officer) or public health worker. (Documentation of first responder/health care employment is required.) *
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