P.R.I.D.E 2019/20 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.

Please contact Megan McCain or Jennifer Furniss with any questions. mmccain@pottstownk12.org or jfurniss@pottstownk12.org
Email address *
Child's Name *
Your answer
Parent/Guardian Name *
Your answer
Home Address *
Your answer
My child will attend P.R.I.D.E at the PMS for the 2019/20 school year *
My child will attend *
Required
My child is in 7th/8th grade and is interested in the Career and Tech Education Program (after school)
Busing *
My child's bus stop is *
Grade *
Student ID Number *
Your answer
Child's Homeroom
Your answer
Primary Phone# *
Your answer
Alternate Phone#
Your answer
Does Your Child Have Insurance Coverage ? *
Policy#
Your answer
Insurance Company
Your answer
Medical Assistance Card (DPA) Card Number
Your answer
Recipient
Your answer
Please list any allergies that your child has:
Your answer
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. *
Your answer
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) *
Your answer
As the parent/guardian : I hereby give my permission to attend the 2019/20 P.R.I.D.E program. (Electronic Signature Approval) *
Your answer
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
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