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*

MaleFemaleNon-BinaryPrefer not to sayOther
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)*

YesNoPrefer not to say
Race/Ethnicity (Please check all that apply)*

Black/African-AmericanWhite/CaucasianMiddle Eastern/ArabAsian/Pacific-IslanderHispanic/LatinxAmerican Indian/Alaskan NativePrefer not to sayOther
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*

Junior (12-22 yrs old)Young Adult (23-29 yrs old)IndividualFamily (Partners + Dependents)Wellness Individual (No Squash)Wellness Family (No Squash)
Do you need financial aid?*

YesNo

Please share your membership interests*

What ways would you like to support the PCS community?*

Volunteering with StudentsMentoring a StudentServing on a CommitteeFundraisingDonationsPrefer not to say
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)

Black/African-AmericanWhite/CaucasianMiddle Eastern/ArabAsian/Pacific-IslanderHispanic/LatinxAmerican Indian/Alaskan NativePrefer not to sayOther
Partner's Gender

MaleFemaleNon-BinaryPrefer not to sayOther
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: