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
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
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
*
$20/year Access Individual
$20/year Access Family (Partners + Dependents)
$20/year Access Wellness Individual (No Squash)
$20/year Access Wellness Family (No Squash)
Please share your membership interests
*
Not Interested
Interested
Very Interested
Squash
Weight Lifting
Cardio Machines
Fitness Classes
Social Events
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
Other Family Members if Applicable (Name, Date of Birth)
Any comments you would like to share with the membership committee?
Submit
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