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* 1. Parent 1 first and last name

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* 2. Parent 2 first and last name (if applicable)

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* 3. Address (include city and zip code)

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* 4. Phone number

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* 5. Email Address

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* 6. What is your preferred method of communication? Check all that apply.

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* 7. Which service are you interested in?

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* 8. Child 1  Name, age and grade

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* 9. Child 2 Name, age and grade

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* 10. Child 3 Name, age and grade

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* 11. Additional children's names, ages and grades

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* 12. Will the tutor/caregiver be preparing meals and/or snacks?

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* 13. Anyone in the home with allergies? (check all that apply)

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* 14. If you have pets, please tell us about them here.

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