This Survey has been created by the NHA IT Department and Surveys should never ask for any sensitive or secure data. Do not provide passwords, SSN, credit card numbers, identification numbers, or any other sensitive information.

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* Program Option

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* Site Preference:

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* Site Preference #2:

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* Has the child you are applying for previously been enrolled in our program?

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* If Yes

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* Is any member of your household employed with NHA?

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* If yes:  Name of Employee:

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