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2. 
3. Employee Childcare Summer Fun Program
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. Best Email Address:*
15. Other Parent/Guardian Contact Information
17. Parent/Guardian Name:*
18. Relationship to Child(ren):*
20. Best Phone Number:*
21. Best Email Address:*
23. 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.
25. Full Name:
26. Relationship to Child(ren):
28. Best Phone Number:
32. Full Name:
33. Relationship to Child(ren):
35. Best Phone Number:
39. Full Name:
40. Relationship to Child(ren):
42. Best Phone Number:
44. Child(ren) Information
46. Family Pickup Password*
48. Child 1 Full Name:*
49. Child 1 Date of Birth:*
    Child 1 Date of Birth:
51. Please list any allergies or dietary restrictions for this child. Enter N/A if there are none.*
52. Please list any medications that staff may need to assist with. Enter N/A if there are none.*
56. Child 2 Name:
57. Child 2 Date of Birth:
    Child 2 Date of Birth:
59. Please list any allergies or dietary restrictions for this child.
60. Please list any medications that staff may need to assist with.
64. Child 3 Name:
65. Child 3 Date of Birth:
    Child 3 Date of Birth:
67. Please list any allergies or dietary restrictions for this child.
68. Please list any medications that aftercare staff may need to assist with.
72. Which weeks do you anticipate utilizing this program?

    Check all that apply.

    1. June 21-25
    2. June 28-July 2
    3. July 5-9

    1. July 12-16
    2. July 19-23

    1. July 26-30
    2. August 2-6
74. Please enter any other pertinent information or questions regarding the City Employee Childcare Summer Fun program.
76. Thank you for taking the time to complete this form as accurately as possible!
Leave This Blank:


78. Submit

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