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In accordance with the Children's Online Privacy Protection Act a person must be 13 years of age or older to complete and submit this form.

NOTE: Our "Rate & Dates" brochure consists of eight pages and would be cumbersome for you to copy. We would like you to have the number of "Rates and Dates" that you will realistically need for the number of persons that you serve. In addition to the "Rates and Dates" brochures that are mailed twice annually, we would like very much to send to you information packets which each supervisor can keep on file as a resource.

If you are with a PROVIDER AGENCY, please fill out the following:
   
Name:
Name of agency:
Address:
City: State: Zip Code:
Phone #: Email address:
Agency Website:
Total number of individuals served:
Residential: Day Programs:
Family Support:
How many supervisors are there in your agency:
Do you also serve children/youth? Yes No
 
If you are an INDIVIDUAL or a FAMILY MEMBER or FRIEND, please fill out the following:
 
Name:
Address:
City: State: Zip Code:
Phone #: Email address:
 
Would you like to refer a friend?
 
Name:
Address:
City: State: Zip Code:
Phone #: Email address:
 
 
 
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