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Titusville YMCA
Nita M Lowey 21st Century Community Learning Center
2020-2021 Enrichment Program
Tentative Dates:
Summer - June 15 - August 21, 2020
School Year - September 1, 2020-June 20, 2021
For Students Entering K-6th Grade in Fall 2020
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Applying for:
*
Summer 2020
School Year 2020/2021
Select all that apply
Summer 2020
School Year 2020/2021
Select all that apply
Child's Information
Child's First, Middle Initial, and Last Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Age
*
Your answer
Child's Gender
Your answer
Child's grade and school attending in the Fall
*
Your answer
Does your child have an IEP?
*
Yes
No
Are you willing to share his/her IEP with us?
*
Yes
No
Not Applicable
Student resides with:
*
Both Parents
Mother Only
Father only
Mother/ Stepfather
Father/ Stepmother
Grandparents
Foster Parent
Other
(Check one)
Both Parents
Mother Only
Father only
Mother/ Stepfather
Father/ Stepmother
Grandparents
Foster Parent
Other
(Check one)
Who has custody?
Your answer
Does parent/guardian have court ordered custody papers? (Note: The Y may require a copy of court orders)
*
Yes
No
Not Applicable
Attendance
Minimum attendance of 3 days per week is REQUIRED. Student attending 5 days per week have first preference.
My Child will attend:
Monday
Tuesday
Wednesday
Thursday
Friday
Check all that apply
Monday
Tuesday
Wednesday
Thursday
Friday
Check all that apply
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