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Cal Address: City Primary Hours of Care: From to State FIRST Zip Code Days of the Week in Care: c M c T c W c Th c F Meals Served While in Care: AM Snack and PM Snack Family Information Child Lives With: Custody: c Mother c Father c Both c Other Mother s Name Father s Name Address Address City State Zip Code City Home Phone: Home Phone: Employer: Employer: Address: Address: City State Zip Code City Work Phone: Cell: Work Phone: Email: Emai.

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