PCC Preschool Registration
Child's Information
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Please Select
Boy
Girl
Parent & Sibling Information
Mother's Name
*
First Name
Last Name
Mother's E-mail
*
example@example.com
Mother's Mobile
*
Please enter a valid phone number.
Mother's Occupation
Address (If different from child's, please complete)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Name
*
First Name
Last Name
Father's Email
*
example@example.com
Father's Mobile
*
Please enter a valid phone number.
Father's Occupation
Address (If different from child's, please complete)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Siblings? If so, please add names and ages.
OPTIONAL!
Additional Questions
Because we are licensed by the State of California, we must follow the vaccine guidelines from the California Department of Public Health. Is your child up-to-date on childhood vaccines?
*
Please Select
yes
no
Has your child attended a different school before?
*
Please Select
yes
no
If yes, what was the reason for leaving?
Does your family attend church?
Please Select
yes
no
If yes, where do you attend?
How did you hear about us?
*
Program Interest
Select all programs you are interested in
Preschool / Junior Kindergarten
*
Preschool (2 Day, 9am - 12pm)
Preschool (3 Day, 9am - 12pm)
Preschool (5 Day, 9am - 12pm)
Junior Kindergarten (5 day, 9am - 1pm)
Extended Care
*
None
Morning Care (8am - 9am)
Lunch Bunch (12pm-1pm)
After Care (1pm - 3pm)
Comments or Questions?
OPTIONAL!
Submit Form
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