DMS BSP/ASP Registration Form
The 21st Century Community Learning Centers program is a free Learning Center program for students that offers a variety of stimulating activities to promote school success and personal well-being in a safe environment. Active attendance and engagement are essential to the students’ and program’s success.
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Email *
Please check the program you are interested in. *
Required
Student First Name *
Student Last Name *
Student Grade Level *
Address *
Parent/Guardian Name *
Parent/Guardian Phone Number *
Emergency Contact 1 *
Emergency Contact 2 *
Medical conditions or allergies that the program staff should be aware of: *
Dismissal (note - the Transportation Office determines eligibility for transportation.  If your child is eligible for bussing, you will receive a letter in the mail) *
Who is authorized to pick up your child from the program? *
Photographs:  From time to time, your child may be photographed and/or videotaped while participating in program activities and they may appear in the Dunkirk Observer, the Dunkirk CSD website or social media sites, or other school related publications. *
Student Surveys:  Occasionally we ask our students to participate in surveys about their interests so that we can plan our program to fit their needs. *
Walking Field Trip: From time to time, it may be necessary to go for an educational walk in and around the school grounds.  This may include crossing the street, trips to local park areas, other school district buildings or other areas of interest such as the Dunkirk Public Library. *
Academic Data: We are required to submit academic data to our program evaluators to show that our program is effective and to continue to improve our program. *
Parent Signature (please type your name) *
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