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21st Century Student Registration Form 2021 2nd-5th Grade Only (If interested)
Please complete the following registration form regarding your student if you are interested in participating in the after school program. This registration form is for Virtual and if we come back to school. Any questions, contact Debby Korder Google Voice # (702)723-8388. After School Program is Monday-Thursday 3:00-6:00 pm Online.
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* Indicates required question
What school do you go to?
*
Manch Es
What is your teacher's name?
*
Your answer
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Home Address
*
Your answer
Student #
*
Your answer
Grade
*
Choose
2nd
3rd
4th
5th
Gender
*
Female
Male
Prefer not to say
Other:
Mother/Guardian Name
*
Your answer
Mother/Guardian Address
*
Your answer
Mother/Guardian Phone Number
*
Your answer
Mother/Guardian Email Address
Your answer
Father/Guardian Name
*
Your answer
Father/Guardian Address
*
Your answer
Father/Guardian Phone Number
*
Your answer
Father/Guardian Email Address
Your answer
Emergency Contact #1: Name/Relationship/Phone Number
*
Your answer
Emergency Contact #2: Name/Relationship/Phone Number
*
Your answer
If legal restrictions are in effect. List anyone NOT allowed to see student and/or NOT allowed to pick up student per legal restriction.
Your answer
Does your child have any health issues (allergies, medication, asthma, diabetes, epilepsy etc.) or health information we should be aware of (please explain)?
*
Your answer
What is your student's Lunch Status?
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Free
Reduced
Other
Does your student receive english language learner services? (Limited English Proficient)
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Yes
No
Does your student receive Special Education services?
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Yes
No
What is your student's ethnicity?
*
Choose
Hispanic/Latino
White/Non-Hispanic
African American
American Indian/Alaska Native
Asian
Pacific Islander
Other
What Club would you like to join? (Pick your top 3)
*
STEAM
Chocolate Factory/ Cooking
Virtual Field Trips
Zoology
Games
Creative Writing
Relax and Paint
Required
Please check one of the following
*
My child is allowed to sign themselves out and walk home when the Afterschool Program ends. First and Second Grade students must either walk home with a sibling or be picked up.
My child will be picked up when the Afterschool Program ends. First and Second Grade students must either walk home with a sibling or be picked up.
Required
Name(s) of authorized person(s) to sign out student
*
Your answer
I agree with the Afterschool Program rules and expectations including the “3 Strike” policy for behavior and late pick-ups (sign/enter name and date)
*
Your answer
I give my child permission to participate in the Afterschool Program (sign/enter name and date)
*
Your answer
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