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21st Century Community Learning Centers Electronic Enrollment Form
This form is to be used for students enrolled into the 21st CCLC program. This form is only valid for 2020-2021 school year.
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Email
*
Your email
STUDENT INFORMATION
Student Name:
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Your answer
Student OSIS (I.D) Number:
Your answer
School:
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Your answer
Current Grade Level:
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Your answer
Date of Birth:
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MM
/
DD
/
YYYY
Sex:
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Female
Male
Prefer not to say
Other:
Home Mailing Address:
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Your answer
City:
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Your answer
State:
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Your answer
Zip Code:
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Your answer
Home Phone Number:
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Your answer
Student Participant's Email Address:
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Your answer
Racial/Ethnic Group (Optional):
American Indian/Alaska Native
Black or African American
Hispanic or Latino
Asian
White
Pacific Islander
Two or more races
Other
Clear selection
Language(s) Spoken at Home:
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Your answer
Parent/Guardian Information
Name of Primary Parent/Guardian 1:
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Your answer
Guardian Title:
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Mother
Father
Grandmother
Grandfather
Other:
Language(s) Spoken:
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Your answer
Address (if different from student's):
Your answer
Home Phone Number:
*
Your answer
Work Phone Number:
Your answer
Cell Phone:
Your answer
Parent/Guardian's Email Address:
*
Your answer
Name of Primary Parent/Guardian 2:
Your answer
Guardian Title:
Mother
Father
Grandmother
Grandfather
Other:
Clear selection
Language(s) Spoken:
Your answer
Address (if different from student's):
Your answer
Home Phone Number:
Your answer
Work Phone Number:
Your answer
Cell Phone:
Your answer
Email:
Your answer
Parent/Guardian Signature Verification - By printing your name here you agree to give your child permission to enroll and participate in the remote 21st Century Community Learning Centers program.
*
Your answer
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