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Complete the questions to be selected to experience Respite Recess!
11
Questions
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1
Parent/Guardian
*
This field is required.
First Name
Last Name
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2
Phone Number
*
This field is required.
Area Code
Phone Number
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3
Email
example@example.com
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4
Select a city near you.
*
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Laveen
Phoenix
Glendale
Gilbert
Scottsdale
Maricopa
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5
Select one that is most important to you.
*
This field is required.
Running errands
Date night
Self-Care time
Staycaction
Working
Vacation
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6
Select one that is most important for your child/children.
*
This field is required.
Social skills & interaction with peers
Cognitive development & learning
Emotional support & attachment
Creativity & self-expression
Physical activity & health
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7
What is your child/children food/snack preferences?
*
This field is required.
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8
Would you prefer access to pick-up & drop-off transportation?
*
This field is required.
YES
NO
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9
Select the Recess Block that you would reserve most.
*
This field is required.
12p-4p
4p-8p
8p-12a
1p-5p
5p-9p
9p-1a
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10
Select the day that you would reserve most.
*
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Monday
Tuesday
Wednesday
Thursday
Friday
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11
How likely are you to reserve Respite Recess events & activities for your child/children?
*
This field is required.
1
2
3
4
5
Not likely
Very likely
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