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Child Care Center Name*

Invalid Input. Please enter the child care center's name.

Child Care Center Director Name*

Invalid Input. Please enter the director's name.

Director's Email Address*

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Number of preschool aged children at facility*

Invalid Input. Please enter only digits in this field.

Child Care Center Location*

Invalid Input. Please enter your address in the 12345 Main Street format.

Director's Phone Number*

Invalid Input. Please enter the facility's number as (804-123-4567).

Number of preschool classes per facility*

Invalid Input. Please enter only digits in this field.

Age group *

Toddler (1 - 2)

Pre-K (3 - 4)

School Aged (5 and up)

Please select all groups that apply.

This application is an indicator that you are interested in receiving visits to your facility from the Mobile Library Service. It does not guarantee that this service will be available to your location at this time. Upon receipt of the application, a staff member will be in contact with you to discuss your service options.*

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Spam Prevention*

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Outreach Child Care Center Form

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Outreach Child Care Center Form

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