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* 1. Submitted By:

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* 2. Parent Name:

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* 3. Child

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* 4. Child (if more than 2 children were in care, please include in Comments below):

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* 5. Date/Time:

Start:
End:

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* 6. Provider Name

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* 7. Type of Care Used (check all applicable):

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* 8. Comments/Questions/Concerns:

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