PBHS Enrollment 2023.24 
Please fill out entire form for each student enrolling in the program.
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Email *
Student's Name: Last *
Student's Name: First *
Student Birth Date *
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DD
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Grade Level: *
Parent/Guardian Name(s) *
Parent/Guardian Email Address (NOT student email) *
Preferred Contact #1 (Name and Number) *
Preferred Contact #2 (Name and Number) *
Preferred Contact #3 (Name and Number) *
Primary Mailing Address *
Emergency Contact #1 : Name and Phone Number (Not listed above) *
Emergency Contact #2 : Name and Phone Number (Not listed above) *
List those individuals allowed to pick up your student from the program and their phone numbers:
Initial here to give your child permission to sign him/herself out at the end of the program day.
Can this student have a photographed published? *
We have easy access to reliable internet *
Grant Required Questions
World Vision uses the following information for the sole purpose of grants and fundraising. All information will remain confidential and anonymous.
Student Ethnicity *
Gender *
Is the student eligible for free and reduced lunch at school? *
Does the student have an IEP or 504 plan? *
Please select the type of household the student resides in the majority of the time: *
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