21st Century Community Learning Centers

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Steam Ahead 2022-2023 School Year

Email *

Student's Name *

Homeroom or referring teacher's name

Date of Birth *

YYYY

Home address *

Current Grade *

Gender *

Male

Female

Lunch Status *

Free / Reduced

Full pay

Ethnicity / Race *

Caucasian

Black /African American

Native American

Asian

Hispanic / Latino

Pacific Islander

Parent / Guardian Name *

Parent / Guardian Address *

Parent / Guardian Email & Phone number

Parent / Guardian Name

Parent / Guardian Address

Parent / Guardian Email and phone number

Emergency Contact Name & phone number *

Emergency Contact Name & phone number

Doctor / Primary Care Provider Name *

Does your child have any known allergies? *

I give the 21st CCLC:STEAM AHEAD staff permission to administer first aid to my child, and to act as "loco parentis" for my child in case of an emergency. In case of emergency, if neither the parent/guardian nor the emergency contacts can be reached, I give permission to the 21st CCLC: STEAM AHEAD staff to make whatever arrangements seem necessary to provide for my child. Indicate yes with your signature (may be typed). *

I grant The Discovery Center permission to use my child's pictures in any campaign designed to inform the public of services and programs available through the Discovery Center. This includes newspaper articles, slide presentations to various organizations, brochures, flyers and other advertising media. Indicate yes with your signature(may be typed). *

The transportation I prefer for my child at the end of each program day is: *

SOCSD bus ( I am aware that an adult must be present at the time of drop off.)

Car pick-up by myself or someone on my emergency contact list

21st CCLC: STEAM AHEAD uses student report cards and state test scores to track student progress and program success. I give permission for the 21st CCLC: STEAM AHEAD staff to talk to my child's teacher, visit my child's classroom, view my child's work/materials, conduct screenings on my child, review report cards/tests, and collect data on my child's attendance and behavior records. Indicate your agreement with your signature(may be typed). *

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