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1. Name

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2. Email Address

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3. Phone Number

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4. What is your professional role?

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5. Agency/Entity

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6. Type of Agency/Entity 

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7. Agency/Entity Phone Number

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8. Agency/Entity City

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9. Agency/Entity County

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10. Please describe the community you serve.

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11. Approximately how many families do you plan to share these resources with?

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12. Approximately how many children could be impacted by sharing these resources with those families?

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13. What age range are the children in the homes you would be targeting?

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