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Facility/Member Name*

Facility's Member Number*

Facility Address*

Facility Phone Number*

Facility Email Address*


Parent's Full Name*

Parent's Full Address*

Parent Phone Number

Parent's ID / Driver's License #

Child's Name*

Child's Date of Birth*

Privacy Disclosure: All information Requested and Provided will be held fully secure by all Parties and used solely for the purpose of providing Program Assistance to Paycare members, only.*

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