Form Center

2. 
3. Employee Childcare Registration Form
5. Employee Parent/Guardian Contact Information
   Contact information for the parent/guardian who is a City employee should be keyed in here.
7. Employee Parent/Guardian Name:*
8. Relationship to Child(ren):*
10. Best Phone Number:*
11. City Department:*
13. Other Parent/Guardian Contact Information
15. Parent/Guardian Name:*
16. Relationship to Child(ren):*
18. Best Phone Number:*
20. Other Adults Authorized to Pick Up
    You may amend the list of additional adults authorized to pick up by emailing recinfo@pbgfl.com at any time.
22. Full Name:
23. Relationship to Child(ren):
25. Best Phone Number:
29. Full Name:
30. Relationship to Child(ren):
32. Best Phone Number:
36. Full Name:
37. Relationship to Child(ren):
39. Best Phone Number:
41. Child(ren) Information
43. Family Pickup Password*
45. Child 1 Full Name:*
46. Child 1 School:*
47. Child 1 Grade:*
    -- Select One --Kindergarten1st2nd3rd4th5th
48. Child 1 Date of Birth:*
    Child 1 Date of Birth:
50. Please list any allergies or dietary restrictions for this child. Enter N/A if there are none.*
51. Please list any medications that aftercare staff may need to assist with. Enter N/A if there are none.*
55. Child 2 Name:
56. Child 2 School:
57. Child 2 Grade:
    -- Select One --Kindergarten1st2nd3rd4th5th
58. Child 2 Date of Birth:
    Child 2 Date of Birth:
60. Please list any allergies or dietary restrictions for this child.
61. Please list any medications that aftercare staff may need to assist with.
65. Child 3 Name:
66. Child 3 School:
67. Child 3 Grade:
    -- Select One --Kindergarten1st2nd3rd4th5th
68. Child 3 Date of Birth:
    Child 3 Date of Birth:
70. Please list any allergies or dietary restrictions for this child.
71. Please list any medications that aftercare staff may need to assist with.
73. Daily Transportation Needs
    Please notify recinfo@pbgfl.com if your child is not attending school or will not need bus transportation on a particular day.
75. Is bus transportation required?*

    1. Yes

    1. No
77. If yes, what time does the school day end?
79. Which days do you anticipate utilizing this program?

    Check all that apply.

    1. Everyday
    2. Monday

    1. Tuesday
    2. Wednesday

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


85. Submit

* indicates a required field