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* 1. I attest that I am a first responder/health care professional and my work is focused on the battle against the Coronavirus emergency efforts.  At present, I have also exhausted all viable options for child care.

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* 2. My employer and my position/job title:

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* 3. My full name:

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* 4. My Child or Children's  Full Name(s):

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* 5. My Child or Children's Age(s):

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* 6. There will be forms to complete upon child care registration.  Please share any special needs that we should be aware of as we prepare for child care:

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* 7. Please check the boxes of times that you may need for child care which will allow you to do your important work.  Note - You would be able to drop off or pick-up your child(ren) any time during the 8:00 am -6:00 pm window.  The below blocks are basically am and pm and will assist us in the organization and establishing of administrative and volunteer schedules.

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* 8. My best phone number: Note - cell number preferred and will be confidential.

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* 9. My best email address:

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* 10. (Optional) Please share anything else that you feel would be helpful for us to to know.

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