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Care Type

Regular Before/After School Care

Summer Camp

Drop-in Care Only

Weather Related Delays/Early Dismissals

Home Phone

For Regular Before/After School Care, select days needed

AM Care Only

PM Care Only

Both AM and PM Care

Home Address *

Mobile Phone

Enter Special Needs Below

Select Times Needed

AM Care Only

PM Care Only

Both AM and PM Care

Child Name or Troop Number *

Parent/Guardian/leader Name *

Email

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