Greene Fall 2021 Student Application

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Dear Parents/Legal Guardians,
The 21st Century after school program will be held this year 2021-2022 starting Tuesday, October 5, 2021, and ending on Thursday, June 9, 2022. The program will begin at the end of the regular school day until dismissal at 5:15 PM from the Greene School playground on Grinnell Street. Students are dismissed to a person 18 years or older who is on the approved list of people for dismissal on this registration form. A healthy snack will be giving to students at the beginning of the after school program. Students will be provided with homework help and engaging enrichment activities that will support their academic learning. There will be no bus this year for students at dismissal. The 21st Century after school program is provided at no cost to you and is available for students in first, second, third, fourth, and fifth grades.

Email *

I give permission for my son/daughter to be photographed/video and for the image and his/her work to be published on the school and/or district website, newspapers, and other media sites. The purpose of this is to share the program and its achievements with others.

Yes

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Parent/ Legal Guardian Name *

I agree to send my son/daughter to the after school program all four days each week; Mondays, Tuesdays, Wednesdays, and Thursdays. *

YES

Student's Full Name *

Student Date of Birth *

2021-2022 Grade Level - The 21st Century program is available for student in grades one, two, three, four and five. *

2021-2022 Classroom Teacher

Address *

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