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Alternative Payment Program Application
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2026-10-05T13:42:48-07:00
Alternative Payment Program Application
Parent / Guardian A
First Name
(Required)
Last Name
(Required)
Email Address
(Required)
Phone Number
(Required)
Gross Income
(Required)
Source of Income
(Required)
Parent / Guardian B
First Name
Last Name
Email Address
Phone Number
Gross Income
Source of Income
Family Information
Number of Family Members
(Required)
Street Address
City
State
ZIP Code
Child Information
First Name
(Required)
Last Name
(Required)
Date of Birth
(Required)
Does the child have any special needs?
Primary Language
(Required)
Days and hours of care needed
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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