P.R.I.D.E 2020/21 Online Registration Form
Please fill out the form below and hit "Submit" at the bottom of the page. Do not hit "Request Access to Edit" at the top of the page or your information will not be saved.

This registration is for the VIRTUAL P.R.I.D.E program. If we return to school in January, so will P.R.I.D.E.

Please contact Megan McCain or Jennifer Furniss with any questions. mmccain@pottstownk12.org or jfurniss@pottstownk12.org
Email address *
Parent/Guardian Name *
Contact Phone # *
Alternate Phone # *
Student ID Number *
Child's Name *
Home Address *
Student School Email Address *
Gender *
Ethnicity *
Grade *
Student Homeroom Teacher
Student ELA Teacher *
Student Math Teacher *
My child will attend PMS PRIDE After School on: *
Required
My child is in 7th/8th grade and is interested in the Career and Tech Education Program (after school)
Clear selection
Does Your Child Have Insurance Coverage ? *
Policy#
Insurance Company
Medical Assistance Card (DPA) Card Number
Recipient
Please list any allergies that your child has: *
Please list the name(s) of individual(s) (designees) other than yourself that you authorize to pick up your child. Please have these individuals bring and show a current photo ID to P.R.I.D.E staff at time of pick up. *
As the parent/guardian: I hereby give P.R.I.D.E my permission to take photos of my child for social media and marketing purposes to promote the program. (Electronic Signature Approval) *
As the parent/guardian : I hereby give my permission to attend the 2020/21 P.R.I.D.E program. (Electronic Signature Approval) *
Date of Electronic Signature *
MM
/
DD
/
YYYY
P.R.I.D.E is a 21st Century Community Learning Center program Sponsored by the Pennsylvania Department of Education
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Pottstown School District. Report Abuse