I am the *

First Name *

Last Name *

Phone *

Email *

In what location will PEP take place ? *

Any Alternative Space? *

Type of Enrichment Program Interested In *

Enrichment Program Interested In (Nursery & Daycare) *

Enrichment Program Interested In *

Does your school or organization follow the DOE Holiday Schedule ? *

Input All Grade Levels To Service *

Is there programming on parent teacher conference days? *

Any IEP participants? *

School Type *

School *

Address *

City *

Zip/Postal Code *

State/Province *

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

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

Overall anticipated number of participants to be serviced per 30 minutes (Nursery & Daycare) *

Overall number of participants to be serviced in the program? *

Overall Anticipated Number of Participants to be Serviced per Hour? *

Anticipated Hours Per Day *

Anticipated Hours Per Day (Nursery & Daycare) *

Anticipated Start Time (Start time must be 2+ hours before end time) *

Anticipated End Time (End time must be 2+ hours after start time) *

Anticipated Start Date *

Anticipated End Date (Minimum Engagement June) *

Anticipated End Date (School Sponsored - Nursery & Daycare) *

Do you have the allocated estimate budget to implement the program chosen above? *

Do you confirm you do not have a budget to implement PEP? *

Estimate Budget Required for Implementation of PEP School Hours? *

Estimate Budget Required for Implementation of PEP Holiday or Summer Camp Hours? *

Choose PEP Payment Option *

Choose PEP Payment Option-Camps *

PEP Additional Comments *

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