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If you have more than two children needing care, please submit an additional form. You may use your TAB key to move forward through the fields.
* = required field.
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* First Name
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* Last Name
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* Address
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Apt #
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* City
* State
* Zip Code
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* Phone
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Alternate Phone
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* E-mail
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* Employer
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Spouse's Employer
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Have you used our service before?
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Yes
No |
* You may be eligible to receive assistance with paying for child care. Is your household income less than…
$25,660 for a family size 2
$32,180 for a family size 3
$38,700 for a family size 4
$45,220 for a family size 5
$51,740 for a family size 6
$58,260 for a family size 7
$64,780 for a family size 8
Not applicable
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Child's First Name
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Boy
Girl
Expecting
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* Date of Birth
(If expecting, enter anticipated date of birth.)
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Month___Day____Year
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* Days Care Needed
(Check all that apply.)
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* Hours Care Needed
(List specific hours, ex. 9am-5pm.)
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* Date Care Needed
(Enter a specific date.)
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Month___Day____Year
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* Type of Care
(Check all that apply.)
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If care is needed for a school age child, provide the name of school your child attends.
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* Desired location of care
(List multiple towns or zip codes)
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Child's First Name
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Boy
Girl
Expecting
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* Date of Birth
(If expecting, enter anticipated date of birth.)
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Month___Day____Year
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* Days Care Needed
(Check all that apply.)
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* Hours Care Needed
(List specific hours, ex. 9am-5pm.)
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* Date Care Needed
(Enter a specific date.)
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Month___Day____Year
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* Type of Care
(Check all that apply.)
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If care is needed for a school age child, provide the name of school your child attends.
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* Desired location of care
(List multiple towns or zip codes)
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Additional Comments
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