Short-Term Care Application

Date(s) care is required
Day(s) your child will attend PCC
Child's Name
Child's Address
Parent Preferred Phone Number
Who will be responsible for dropping off/picking up your child to the Center? (Include name and relationship)
What time will your child arrive at the PCC?
What time will your child depart from the PCC?
Child's General Health
Please indicate any allergies, medications, special needs, or limitations.
Does your child have any dietary needs or food allergies/restrictions?
Parent #1 Name
Parent #1 Business Address
Parent #2 Name
Parent #2 Business Address
If attending an activity on campus, please give the location and telephone number. 
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