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2020-2021 21st CCLC Schuylkill ACHIEVE AfterSchool Registration Form
Please complete a form for each child you are registering for the 2020-2021 21st CCLC Schuylkill ACHIVE AfterSchool Middle School Program.
The completion of the form will act as an electronic signature of the parent listed in the form.
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* Indicates required question
Email
*
Your email
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Student's Grade
*
Grade 5
Grade 6
Grade 7
Student's Homeroom Teacher
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's Math Teacher
Your answer
Student's English/Language Arts Teacher
Your answer
Parent's First Name
*
Your answer
Parent's Last Name
*
Your answer
Home Address
Your answer
Home Phone number
*
Your answer
Cell Phone number
*
Your answer
Parent's work number
Your answer
Emergency Contacts: In an emergency situation, or if the student is absent without an excuse, and a parent or guardian cannot be reached, please contact the following: (First and Last name, Phone number)
*
Your answer
Second Emergency Contact (First and Last name, Phone number)
Your answer
Please list any medical conditions or allergies:
Your answer
Please list any dietary restrictions:
Your answer
My student will attend: (Please note, On-Site session will be limited to 25 students each day. We may have to rotate students)
VIRTUAL Morning Session (7:00-7:30)
ON SITE Afternoon Session (2:45-4:45)
Monday
Tuesday
Wednesday
Thursday
VIRTUAL Morning Session (7:00-7:30)
ON SITE Afternoon Session (2:45-4:45)
Monday
Tuesday
Wednesday
Thursday
My student will be picked up by (list first and last name, phone number)
Your answer
My student will walk home
Yes
No
Clear selection
Is there anyone else authorized to pick up your child in the event the above person is unavailable. (Please list the individual(s) below:
Your answer
Parent/Guardian check list (Please read and check all that apply)
I have completed the Emergency Plan Form (Additional link in email)
I have received and acknowledge the Safeguarding Sensitive School, Teacher, and Student Data Form. (WILL BE SENT IN CLASSTAG AFTER YOU REGISTER)
I have received a copy of the Parent Handbook (WILL BE SENT IN CLASSTAG AFTER YOU REGISTER)
My child is eligible to receive free and reduced meals. *Your child does not need to qualify for free or reduced lunch to be able to participate in Schuylkill ACHIEVE AfterSchool program)
My child may be photographed in the Schuylkill ACHIEVE program for media purposes. (checking the box signifies a YES)
I have downloaded the CLASSTAG App. (This is needed for communication with the ACHIEVE team)
Do you have any skills, talent, or activities that you would like to share with the 21st CCLC Schuylkill ACHIEVE students during the AfterSchool Program or during a Family Even?
Your answer
Any additional parent or Guardian information you would like to add:
Your answer
Send me a copy of my responses.
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