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Site Name^*

Icon

Street Address Line One^*

Street Address Line Two

City^*

State^*

Zip^*

Phone^*

Organization^*

Contact

Program Setting^*

Counties Served^*

Duration

Grade Level

School Age Activities

Special Designation^*

Staff with National Child & Youth Care Credential (CYC)^*

Total Number of Kids Served Last School Year^*

Total Number of Kids Served Last Summer^*

Enter the average number of youth who participate in 30 or more days of programming annually^*