PCMS Lottery Enrollment/Waiting List

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Please complete this form if you would like to enroll your student at PCMS. If the student enrolling in PCMS has ever had a sibling who has attended PCMS in the past, please indicate below. PLEASE CONTACT THE SCHOOL by phone or email at (530) 872-7277 / jrobbins@pcms.tv TO ENSURE WE HAVE RECEIVED YOUR ENROLLMENT INFORMATION.

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Student's LAST Name *

Student's FIRST Name *

Student's Grade in the 2021-2022 School Year *

New Family or Sibling of PCMS Alumni *

Enrolling student is a sibling of a former PCMS Student

Enrolling student is a new family to PCMS

Name of Student's Current School Attending *

Student's Date of Birth *

Siku

Mwezi

Saa

Student's Gender *

Student's Current School Address, City, and State *

Phone Number *

Please add the BEST number at which we can reach you.

Parent Email *

Contact Name (Parent / Guardian) *

Street Address *

City *

Zip Code *

I certify that I have reviewed this document and to the best of my knowledge, the information contained herein is true and complete. By selecting I AGREE below, I declare under penalty of perjury that I am the parent or legal guardian of the above-named student. *

By choosing "I AGREE" and entering your name in the boxes below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

FULL NAME (Digital Signature) *

Entering your name in the boxes below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

Wasilisha

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