I am the (Parent Sponsored PEP) *

First Name *

Last Name *

Phone *

Email *

In what location will PEP take place ? (Parent Sponsored PEP) *

Any Alternative Space? (Parent Sponsored PEP) *

Type of Enrichment Program Interested In (Parent Sponsored PEP) *

Enrichment Program Interested In (Nursery & Daycare)

Enrichment Program Interested In *

Does your school or organization follow the DOE Holiday Schedule ? (Parent Sponsored PEP) *

Input All Grade Levels To Service (Parent Sponsored PEP) *

Is there programming on parent teacher conference days? (Parent Sponsored PEP) *

Any IEP participants? (Parent Sponsored PEP) *

Number of School Aid Assistance? (Parent Sponsored) *

School Type *

School *

Address *

City *

State/Province *

Zip/Postal Code *

3 weeks are required prior to start date of proposal agreement (Nursery & Daycare) *

3 weeks are required prior to start date of proposal agreement *

Anticipated Start Date (Parent Sponsored PEP) *

Anticipated End Date (Parent Sponsored PEP) *

Anticipated Start Time *

Anticipated End Time *

Anticipated Camp hours per day (PEP Parents) *

Overall anticipated number of participants to be serviced *

Overall anticipated number of participants to be serviced per 30 minutes (PEP Parents) *

Overall anticipated number of participants to be serviced per hour (PEP Parents)

Would you like the PEP participants to split into:

Are you aware parent or guardian will be making direct payment for enrichment programming? *

Are you aware parent or guardian will be making direct payment for camp programming? *

PEP Additional Comments (Parent Sponsored PEP) *

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