Short-Term Care Preregistration Form

Attendance Days

What days will your child attend PCC?

Drop-off Time

What time will you drop your child at the PCC?

Pickup Time

What time will you pick up your child from the PCC?

Child's Information

First

Last

Child's Birthdate

Child's Present Age

Parent #1 Information

First

Last

Penn ID

Required if applicable

Address

City/Town

State/Province

ZIP/Postal Code

Parent #1 Preferred Phone

Parent #1 Secondary Phone

Optional

Parent #1 Email

Parent #1 Penn Affiliation

Parent #1 Penn School/Department

Required if applicable

Parent #2 Information

First

Last

Parent #2 Penn ID

Required if applicable

Parent #2 Address

If different from Parent #1

Address

City/Town

State/Province

ZIP/Postal Code

Parent #2 Preferred Phone

Parent #2 Secondary Phone

Optional

Parent #2 Email

Parent #2 Penn Affiliation

Parent #2 Penn School/Department

Required if applicable

Health Overview

Does your child receive support services or have special physical, medical, or dietary needs? Allergies?

Explanation

If yes, please briefly explain support services, allergies, or special physical, medical, or dietary needs.

Toilet Trained

Is your child toilet-trained?

Naps

Does your child nap?

Nap Duration

If yes, for how long does your child nap at a given time?

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

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Short-Term Care Preregistration Form

Child's Information

Parent #1 Information

Parent #2 Information