2019 School-Age Program - Annual Referral Renewal

Basic Facility and Contact Information

7% of survey complete.

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* 1. Name of School-Age Program

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* 2. Location Address

Street

City

Zip

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* 3. Mailing Address (if different)

Street

City

Zip

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* 4. County program is physically located in

Alamance

Caswell

Durham

Franklin

Granville

Orange

Person

Vance

Wake

Other (please specify)

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* 5. Facility Owner / Program Operated By

Name/Organization Name

Phone

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* 6. Site Director

Name

Phone

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* 7. Referral Contact

Name

Phone

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* 8. Website/Social Media Page

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* 9. Please indicate your agreement to the following statement: On behalf of the school age program specified above, I acknowledge receipt of the Child Care Referral Central listing policy and agree to the terms stated therein. Click Here to Review Policy

Yes, I agree.

No, I do NOT agree. I understand that by not agreeing, my program will not be eligible for child care referrals to families seeking child care in my community.

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* 10. Electronic "consent" or lack thereof provided by:

Name

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