2024 PCC Parent/Guardian Questionnaire

Student Name *

First NameLast Name

Nickname/Preferred Name

PCC Student ID Account #*

This is located on your student's acceptance letter.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

IN THE EVENT OF AN EMERGENCY, PLEASE CONTACT:

Parent/Guardian #1 Name*

First NameLast Name

Parent/Guardian Email #1*

example@example.com

Best Phone Number to reach you: *

Please enter a valid phone number.

Alternate Phone Number (Home, work, etc)

Please enter a valid phone number.

Address if different than student's:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian #2 Name

First NameLast Name

Parent/Guardian Email #2

example@example.com

Best Phone Number to reach you:

Please enter a valid phone number.

Alternate Phone Number (Home, work, etc)

Please enter a valid phone number.

Address if different than student's:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Family Physician: *

First NameLast Name

Physician Phone Number:*

Please enter a valid phone number.

Emergency Contact Person: Record the name of a person who would assume temporary care of your child in the event you cannot be reached:

EMERGENCY CONTACT PERSON *

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Dismissal Authorizations: In addition to Parent/Guardians & emergency Contacts, please list all authorized adults who are able to dismiss your child from the program. List name(s), relationship to student and phone number.

All dismissal pickups require photo ID and must be on this pre-approved list to dismiss your student from the dorms. You may add authorized adults in the summer if things change.

Student information

Does the student have any health problems?*

NoYes

If Yes, please explain:

Does the student have any behavioral or psychological problems?*

NoYes

If Yes, please explain:

Will the student require prescription while at PCC?*

NoYes

If Yes, please fill out the Medical form #2 found on our website & Name of Medications:

Is the student currently restricted in any physical activities?*

NoYes

If Yes, please explain:

Is the student allergic to any food, medication or insect bites?*

NoYes

If Yes, please explain:

MY/OUR SIGNATURES

Authorizes the school to release school records (if needed) to Advanced Studies Program (ASP)
Authorizes the ASP to contact our family physician listed above if they are unable to reach me/us.
Certifies my child and I have read, accept, and agree to abide by the Code of Conduct (pccasp.org)
Indicates that I/assume all responsibility and will make restitution for any damages to college property which may be directly attributed to my child.
Authorizes a press/website release for PCC/ASP picture and name.

A DEPOSIT of Two Hundred-Fifty Dollars ($250.00) must be submitted with this questionnaire to register my child.

By submitting your name below, you are electronically signing your names.

N.B. Please be advised that any medical information you provide will be disclosed only to those people who have a need to know in order to provide for the safety of your child. You have the right to request restrictions on the disclosure of your child’s medical information. While we will consider your request, we are not required to accept it.

Student Name*

First NameLast Name

Parent/Guardian Name *

First NameLast Name