Step 1 of 4

Full name*
Address
Street Address Address Line 2 City Ohio ZIP Code
Phone number

Work and School
Enter your employer's information below
If you have more than one job, click the (+) to add another.
Name Address City State Zip code
Enter your school's information below:
If you have attend more than one school, click the (+) to add another.
Name Address City State Zip code
Work and School Schedule
In completing the below, please use EARLIEST time you NORMALLY leave for work and the LATEST time you NORMALLY can expect to be home.

If periodically you leave earlier or later or work outside these NORMAL hours, don’t use that time but explain that after completing this table.
Employer
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for employer 1
Do you need to add more employers?
- Yes
- No
Employer 2
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for employer 2
Employer 3
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for employer 3
School
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive School Leave School Arrive Home
Explanation for school (if applicable)
Do you need to add more schools?
- Yes
- No
School 2
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for school 2 (if applicable)
School 3
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for school 3 (if applicable)

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Name	Address	City	State	Zip code

Name	Address	City	State	Zip code

Day	Leave Home	Arrive Work	Leave Work	Arrive Home

Day	Leave Home	Arrive Work	Leave Work	Arrive Home

Step 1 of 4

Work and School

Work and School Schedule