PCS Membership Application
After completing this application, Elise Malongi will contact you regarding availability and financial aid. PLEASE NOTE: This application does not guarantee membership; we try our best to fill spots on a rolling basis, but with high demand and limited spots, we need to balance various factors - including socioeconomic status and racial diversity - in order to uphold our commitment of being an intentionally diverse and inclusive community. For more information about our enrollment policy, please contact Elise Malongi.
Member Name
*
First Name
Last Name
Member Email
*
example@example.com
Member Phone
*
-
Area Code
Phone Number
Member Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-Binary
Prefer not to say
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)
*
Yes
No
Prefer not to say
Race/Ethnicity (Please check all that apply)
*
Black/African-American
White/Caucasian
Middle Eastern/Arab
Asian/Pacific-Islander
Hispanic/Latinx
American Indian/Alaskan Native
Prefer not to say
Other
Occupation or Professional Interests?
*
What languages do you speak?
*
Member Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
-
Area Code
Phone Number
Membership Type
*
Junior (12-22 yrs old)
Young Adult (23-29 yrs old)
Individual
Family (Partners + Dependents)
Wellness Individual (No Squash)
Wellness Family (No Squash)
Do you need financial aid?
*
Yes
No
Please share your membership interests
*
Not Interested
Interested
Very Interested
Squash
Fitness
Events
Cafe
Youth Programs
What ways would you like to support the PCS community?
*
Volunteering with Students
Mentoring a Student
Serving on a Committee
Fundraising
Donations
Prefer not to say
Partner's Name if Applicable
First Name
Last Name
Partner's Date of Birth if Applicable
-
Month
-
Day
Year
Date
Partner's Phone if Applicable
-
Area Code
Phone Number
Partner's Email if Applicable
example@example.com
Partner's Race/Ethnicity (Please check all that apply)
Black/African-American
White/Caucasian
Middle Eastern/Arab
Asian/Pacific-Islander
Hispanic/Latinx
American Indian/Alaskan Native
Prefer not to say
Other
Partner's Gender
Male
Female
Non-Binary
Prefer not to say
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?
Submit
Should be Empty: