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Program Information
First Choice Program Date:
*
Month
Jan
Feb
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Apr
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Jun
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Oct
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Dec
Day
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Year
2011
2012
Second Choice Program Date:
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
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5
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31
Year
2011
2012
First Choice Start Time:
*
Second Choice Start Time:
*
Time Zone:
*
Total Number of Children/Students:
*
Total Number of Adults:
*
School Information
School Name:
*
School Address:
*
City:
*
State:
*
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Marshall Islands
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Northern Marianas Islands
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Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County:
*
Are you a Title 1 or Head Start school in Davidson County:
*
- Select -
yes
no
Contact
Teacher Name:
*
Teacher Email:
*
Teacher Phone Number:
*
Tech Coordinator Name:
*
Tech Coordinator Email:
*
Tech Coordinator Phone Number:
*
Class Information
Grade:
*
Number of Participating Boys:
*
Number of Participating Girls:
*
Will Students Each Have Their Own Computer:
*
- Select -
yes
no
Will Students Have Audio/Video Capability:
*
- Select -
yes
no
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