COV4 Childcare Registration Form
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Youth's Name *
Youth's Age *
Emergency Contact Name *
Emergency Contact Phone *
Emergency Contact Email *
Emergency Contact - Relationship to Youth *
Youth's preferred spoken language *
Youth's preferred gender pronoun *
Disability Justice Resources?
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Allergies or Dietary Restrictions?
Medical Considerations or Other Important Info?
What type of activities or workshops would you like to see happen in the childcare space?
What time will you need childcare?
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