Prime Time Palm Beach County

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To register with PrimeTime PBC please fill out the form below.
Name of Organization:
Mailing Address:
City:               State:                   Zip: 
Main Phone Number:            Fax Number:  
Type of Organization (check all that apply):
CBOSafe SchoolBeaconFor Profit
County/GovmtResource AgencySACCOverlay Provider
Childcare CenterNon-ProfitOther  
Licensure: Yes         No         Exempt
Website (If Applicable):
Funding Sources (mention all that apply to the organization): 
Number of Children Enrolled (by Grade):   K-5:       6-8:       9+: 
Daily Attendance (As of Last Day of School or during Summer Camp):  
Number of Full Time Staff Members:       Number of Part Time Staff Members: 
Days and Hours of Operation:
Monday: to Tuesday: to
Wednesday: to Thursday: to
Friday: to Saturday: to
Sunday: to
Do you have a Summer Camp Program?    Yes         No
If Yes, Number of youth enrolled: 
Summer Camp Days and Hours of Operation:
Monday: to Tuesday: to
Wednesday: to Thursday: to
Friday: to Saturday: to
Sunday: to
Contact # 1 (Required)
     First Name:        Middle Initial:        Last Name: 
Cell Number:        Direct Office Line: 
Title:         E-mail Address: 
Contact Type:
Full Time Part Time Other
Education Level:
High School/GED 2 Year College 4 Year College Graduate Courses
CDA 40 Hour Certificate 120 Hour School Age Certificate
Program Name:
Contact # 2
     First Name:        Middle Initial:        Last Name: 
Cell Number:       Direct Office Line: 
Title:         E-mail Address: 
Contact Type:
Full Time Part Time Other
Education Level:
High School/GED 2 Year College 4 Year College Graduate Courses
CDA 40 Hour Certificate 120 Hour School Age Certificate
Program Name:
Contact # 3
     First Name:        Middle Initial:        Last Name: 
Cell Number:       Direct Office Line: 
Title:         E-mail Address: 
Contact Type:
Full Time Part Time Other
Education Level:
High School/GED 2 Year College 4 Year College Graduate Courses
CDA 40 Hour Certificate 120 Hour School Age Certificate
Program Name:
Login Information
Username:
Password:
Confirm Password:

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Prime Time Palm Beach County, Inc. | 2300 High Ridge Road, Suite 330 | Boynton Beach, FL 33426 |
Phone: 561-732-8066 | Fax: 561-732-8094