2023 Summer Enrollment Form

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Email *

Student Last Name *

Student First Name *

23-24 Grade Level

9th

10th

11th

12th

Graduated Senior (Class of 2023)

Parent/Guardian Name *

Parent/Guardian Phone Number *

Parents/ Guardian Email Address *

Emergency Contact Name & Number *

Does your student have any medical conditions we should be aware of? *

Yes

Please explain any medical conditions that we should know about.

Does your child have any allergies, food or otherwise? *

Yes

If yes, what allergies should we know about?

Does your child need to carry either an epi pen or inhaler? *

Epi Pen

Inhaler

Both

None

I hereby give my child permission to participate in all 21st Century sponsored field trips scheduled throughout the summer. I reserve the right to withhold permission on any specific field trip. I understand that I will be notified of all field trips the week prior. *

Yes

Required

Caregiver Handbook

Yes, we have reviewed and read the Streaks After Hours Caregiver Handbook

No, we have not read the Streaks After Hours Caregiver Handbook

Required

Student Handbook *

Yes, we have read the student handbook

No, we have not read the student handbook

Required

Internet Permission (Handbook, page 9) *

Yes, we agree to the internet permission as outlined in the handbook

No, we do not agree to the internet permission as outlined in the handbook

Skyward Release (handbook, page 9) *

Yes, we agree to the Skyward Release

No, we do not agree to the Skyward Release

Photo Release (handbook, page 9) *

Yes, we agree to the photo release

No, we do not agree to the photo release

Required

By, typing your name below we enroll and acknowledge that we have also received and read the GHS 21st CCLC Handbook. *

College and Career Jumpstart will meet June 26-30 at GJSHS in room A115 from 9-11. Students who would like to attend our college visit, should attended this program *

Yes, I will be attending College and Career Jumpstart

No, I will not be attending College and Career Jumpstart.

Peoria Chiefs Baseball Game June 30. Bus will leave at 5 pm and return at 10 pm (all times are approximate). STUDENTS MUST ATTEND ONE OTHER PROGRAM IN ORDER TO ATTEND THE BASEBALL GAME. *