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1. Update Your Information

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* 1. Provider Name

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* 2. Program Name

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* 3. Phone Number

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* 4. Email Address

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* 5. Website (if applicable)

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* 6. Type Of Care

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* 7. Ages of children you are willing to provide care for:

  6 Weeks 1 Year 18 Months 2 Years 5 Years 12 Years
FROM what age
TO what age

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* 8. Number of Current Openings: enter the number of openings for each age group in the rows below. If you have no openings please enter 0.

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* 9. List ALL Elementary and Middle Schools with bus stops near your home or within walking distance:

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* 10. Transportation: Please check all that apply.

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* 11. Languages Spoken: Check all that apply.

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* 12. Hours of Operation

  Open Close
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 13. Extra Care Services: Check all that apply.

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* 14. Fee Assistance: Check all that apply.

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* 15. Special Needs: Check all that apply.

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* 16. Additional Care Services: Check all that apply.

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* 17. Thanks for your time! Please enter any additional comments below, then click the NEXT button below to go to the next page.

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