Child Care Support Application Form

Name*

First NameLast Name

Company/Institution*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Country*

Email*

example@example.com

Confirm Email*

example@example.com

Number of Children*

Ages of Children*

Career Information*

I confirm that I have an accepted presentation at the MMM 2023 Conference*

NoYes

Funding Information - Please check ALL that apply*

A. Home-based childcare expenses incurred because of MMM 2023 Conference attendance (funds may not be applied to a normal ongoing expense.)B. Travel of a relative or other care provider to my home to care for my child(ren) while I attend the Conference.C. Travel of my child(ren) to the location of a care provider who does not live in my community.D. Travel of a care provider, that does not live with our family, to the Conference with me to care for my child(ren) in Dallas, TX.E. Travel of a care provider, that lives with our family, to the Conference with me to care for my child(ren) in Dallas, TX.F. Child care to be retained in Dallas, TX during conference week.G. Other

Where is the provider traveling to/from?

Where will the children be cared for (city/state/country)?

Where is the provider travelling from?

Please explain necessity in more detail

Please explain

MMM 2023 Child Care Support Application Form

Personal Information