Grade 3 Wait-List 2022-2023
Pierce School Extended Day Application Form
Child's Name
*
First Name
Last Name
Gender
*
She/Her
He/Him
They/Them
Other
Please CHECK the days you are requesting:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Are the days of enrollment flexible?
*
Yes
No
If Yes, 2nd Choice (days of the week):
Parent/Guardian #1 Name
*
First Name
Last Name
Parent/Guardian #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #1 Email
*
example@example.com
Parent/Guardian #1 Cell
*
Please enter a valid phone number.
Parent/Guardian #2 Name
First Name
Last Name
Parent/Guardian #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Cell
Please enter a valid phone number.
Does your child require any special accommodations or support services to be successful in our program? If so, please explain:
Please CHECK ALL information that applies:
*
We need extended day because we work.
We need extended day because we attend school.
Other
If you checked other, please explain:
If accepted, which email address would you like the enrollment packet sent to?
*
example@example.com
Submit
Should be Empty: