Organization Registration Form

Please note that this registration form is for new afterschool programs and existing afterschool programs that have never utilized Prime Time's supports. If your program has, at any point, utilized a Prime Time service (e.g., trainings, ELOs, etc.) you do not need to fill out this form.

Organization Information

Organization Name

Street Address

City

State

Zip/Postal Code

Office Phone

Fax

Website

Licensure

I have a

Tax Status

Primary Contact Information

Salutation

First Name

Middle Name

Last Name

Title

Work Schedule

Staff Type

Works with Primary Grade Levels

Mobile Phone

SMS Consent

Check this box to subscribe to text messages from Prime Time Palm Beach County, Inc. You can expect to receive 3-4 messages per month and can opt-out at any time by texting the word STOP.

I agree to subscribe

Home Phone

Preferred phone number contact

Personal Email

Work Email

Preferred Email Contact Method

Contact Information