Hollywood Baptist Church

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Fri., Jan. 24 (6-9pm), Sat., Jan. 25 (9am - 3:30pm) (lunch will be provided), Sat., Feb. 15 (9am-12pm)
3 sessions

Hollywood Baptist Church
204 Hollywood Blvd SE, Fort Walton Beach, FL 32548

English Childcare: FREE* 17 Miles Away

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Husband First Name
Last Name

Date of Birth

Cell Phone #Format: 555-456-7890
Email Address
Street Address
City
State
Zip
Gender

Wife First Name
Last Name

Date of Birth

Cell Phone #Format: 555-456-7890
Email Address

Mailing Address same as Husband

Street Address
City
State
Zip

Gender

Childcare Do you need childcare?

Yes No

# of Children?

Participating Programs Select Programs You Participate in:

None WIC TANF Unemployment "Step Up" School Lunches

Who is filling out this form ?

Husband

Wife

Bring proof of participation in at least one of those programs and payment for the child care with them to the first class session.

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Funding for this project was provided by the United States Department of Health and Human Services, Administration for Children and Families, Grant: #90ZB0021. These services are available to all eligible persons, regardless of race, gender, age, disability, or religion.

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