Demographic Program Information

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* 1. Contact Information

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* 2. What type of governing body does your program operate under?

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* 3. Is your governing body aware of this project, and if required, have they granted approval of participation?

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* 4. # of Children Served

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* 5. Age Range of Children Served

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* 6. # of children receiving

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* 7. # of staff working

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