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Facility Name *

Email Address *

Facility Address *

Facility Member ID#

Facility Email

Facility Phone# *

Paycare Legal Service Requested *

Select an option

How Many Facilities to Join Paycare Legal? *

2nd Facility to Join

3rd Facility to Join

1st Parent Name, Address, Ph#, Child Name & DOB *

2nd Parent Name, Address, Ph#, Child Name & DOB

3rd Parent Name, Address, Ph#, Child Name & DOB

4th Parent Name, Address, Ph#, Child Name & DOB

5th Parent Name, Address, Ph#, Child Name & DOB

Notes/Comments

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