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Provider Type (choose from options below)
1. Family, friend or neighbor who is not designated as an official day care provider for the child.
2. Day Care Provider
3. Community entity - YMCA, church, etc. not including school programs.
4. School program or setting
5. Foster Care
Grant Manager Signature
Social Worker Signature (when appropriate)
Mental Health Professional (when appropriate)
This field is not part of the form submission.
* indicates a required field