Archived-PCS Membership Application

Archived-PCS Membership Application

As of September 2025 we are no longer using this form! Please review below for updated information!
We have updated our membership process. Please fill out this application instead: PCS Membership Application

Thanks!
Member Name

First NameLast Name
Member Email
example@example.com
Member Phone

Area CodePhone Number
Member Date of Birth

MonthDayYear
Date
Gender

Other
Do you meet child care subsidy income requirements? (Family of 1 < $40,000, 2 < $53,000, 3 < $65,000, 4 < $77,000, 5 < $89,000, 6 < $102,000, 7 < $104,000, 8 < $106,000, 9 < $108,000, 10 < $110,000)
Race/Ethnicity (Please check all that apply)

Other
Occupation or Professional Interests?
What languages do you speak?
Member Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Phone

Area CodePhone Number
Membership Type
Do you need financial aid?

Please share your membership interests

What ways would you like to support the PCS community?
Partner's Name if Applicable

First NameLast Name
Partner's Date of Birth if Applicable

MonthDayYear
Date
Partner's Phone if Applicable

Area CodePhone Number
Partner's Email if Applicable
example@example.com
Partner's Race/Ethnicity (Please check all that apply)

Other
Partner's Gender

Other
Partner's Occupation or Professional Interests?
Please provide name, date of birth, gender, and race for each dependent that you would like included on your membership:
Any comments you would like to share with the membership committee?
Should be Empty: