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B.E.A.R.S. Referral Consent Form

Please complete the form below as accurately as possible, then click on the 'send' button. You can also send this form to us by postal mail, at 4C of the U.P., 104 Coles Drive, Suite F, Marquette, MI 49855.

Child's Name: Date of Birth:
Childcare Provider: Phone Number:
Is child eligible/receiving DHS child care assistance/subsidy? Yes    No    Pending   
Parent/Guardian Name: Phone (Day): Phone (Evening):
Parent/Guardian Address: City:
Reason for Referral:

Your name on this form will be considered your signature. This form is intended to be submitted jointly by both Parent/Guardian and Childcare Provider.

     
Great Start
Marquette / Alger Counties
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104 Coles Drive Suite F * Marquette, Michigan * Phone: (906)228-3362 * Toll Free: (866)424-4532 or 866-4childcare
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