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* 1. Facility Name

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* 2. Contact Person

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* 3. Tell us the number of children ages 0-2 that need child care each shift.

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* 4. Tell us the number of children ages 3-4 that need child care each shift.

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* 5. Tell us the number of children ages 5-13 that need child care each shift.

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* 6. Please provide us with any other comments, issues, or concerns you have regarding staffing and childcare.

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