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2. 
3. Drop-In Employee Childcare Questionnaire & Registration Form
5. This is a drop-in program that does not require a commitment. The purpose of this form is to receive your feedback for childcare. This program is only available for the children of City employees in grades K-8. Children may be dropped off between 7:30am and 6:00pm and only when parents are physically at their workplace. The program will not facilitate E-Learning. Therefore, children will not be permitted to bring any electronics. This information is requested so that we can properly staff our program and offer quality activities.
7. Employee Parent/Guardian Contact Information
   Contact information for the parent/guardian who is a City employee should be keyed in here.
9. Employee Parent/Guardian Name:*
10. Relationship to Child(ren):*
12. Best Phone Number:*
13. City Department:*
15. Other Parent/Guardian Contact Information
17. Parent/Guardian Name:*
18. Relationship to Child(ren):*
20. Best Phone Number:*
22. Child(ren) Information
24. Child 1 Full Name:*
25. Child 1 School:*
26. Child 1 Grade:*
    -- Select One --KindergartenFirstSecondThirdFourthFifthSixthSeventhEigth
27. Child 1 Date of Birth:*
    Child 1 Date of Birth:
29. Is this child's classes currently planned to be held virtually or in person?*

    Please select one.

    1. Virtual

    1. In Person
33. Child 2 Name:
34. Child 2 School:
35. Child 2 Grade:
    -- Select One --KindergartenFirstSecondThirdFourthFifthSixthSeventhEighth
36. Child 2 Date of Birth:
    Child 2 Date of Birth:
38. Is this child's classes currently planned to be held virtually or in person?

    Please select one.

    1. Virtual

    1. In Person
42. Child 3 Name:
43. Child 3 School:
44. Child 3 Grade:
    -- Select One --KindergartenFirstSecondThirdFourthFifthSixthSeventhEighth
45. Child 3 Date of Birth:
    Child 3 Date of Birth:
47. Is this child's classes currently planned to be held virtually or in person?

    Please select one.

    1. Virtual

    1. In Person
49. Anticipated Childcare Needs
    We understand that needs may change. In order to ensure proper staffing throughout the program, please email recinfo@pbgfl.com with any updates to your childcare needs.
51. What time of day do you anticipate utilizing this program?*

    Check all that apply.

    1. Half day AM

    1. Half day PM

    1. Full day
53. What are the anticipated coverage hours that are needed?
55. Which days do you anticipate utilizing this program?

    Check all that apply.

    1. Everyday
    2. Monday

    1. Tuesday
    2. Wednesday

    1. Thursday
    2. Friday
57. Please enter any other pertinent information or questions regarding the City's Drop-In Employee Childcare program.
59. Thank you for taking the time to complete this form as accurately as possible!
Leave This Blank:


61. Submit

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