Self Paced Packets Request

Subsidy Billing/Electronic Attendance

Self-Paced Packet Request Form
All fields marked with* are required and must be completed.
Email
example@example.com
Stars Id Number*
Provider Name*

First NameLast Name
Address to Mail the Packet (PO Boxes are fine)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Requested Packet Language*

EnglishEspañolSomali
Provider Type*

Family, Friend, or Neighbor (FFN)Licensed Family HomeChild Care CenterSchool-Age Only ProgramOutdoor Nature Based Program
Self-paced Packet Requested (Choose all that apply)*

Electronic AttendanceSubsidy Billing
To schedule a live Electronic Attendance session please click the link below:

FFN: https://imaginewa.org/eas-ffn/

LFCCP: https://imaginewa.org/eas-lfccp/
Requester's Name (If you are requesting on someone else's behalf)

First NameLast Name
Would you like your packet emailed or mailed to your address?*

Email meSend it to my house
Do you have a printer or access to a printer to complete this form?*

YesNo
Requester's Email*
example@example.com
Should be Empty:

Subsidy Billing/Electronic Attendance