21st Century Virtual Registration Form
General Registration Form for afterschool virtual programming
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Email *
Student Name
Grade
Birthday
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Home Phone
Parent Cell Phone
Mailing Address
Valid Student email address for connecting with Zoom
Valid Parent email address for connecting with Zoom
ALL 21ST CENTURY PROGRAMMING IS FREE TO STUDENTS.  WE WORK STRICTLY WITHIN A GRANT BUDGET AND WILL PROVIDE PROGRAMMING TO ASSIST STUDENTS IN MEETING ACADEMIC STANDARDS IN CORE SUBJECTS (MATH, READING, SCIENCE AND SOCIAL STUDIES) BY PROVIDING OUT OF SCHOOL TIME SERVICES TO STUDENTS AND THEIR FAMILIES THROUGH COMMUNITY LEARNING CENTERS THAT OFFER AN ARRAY OF ACADEMIC AND ENRICHMENT ACTIVITIES TO COMPLEMENT REGULAR ACADEMIC PROGRAMS.ANY STUDENT IN GRADES 3 THROUGH 8 IS ELIGIBLE TO PARTICIPATE IN WAYNE COUNTY 21ST CENTURY PROGRAM. WE DO NOT DISCRIMINATE ON THE BASIS OF RACE, SEX, OR RELIGION.
Areas you would like your child to work on during 21st Century programming?
I GIVE MY PERMISSION FOR WAYNE COUNTY 21ST CENTURY PROGRAM TO TAKE MY CHILD’S PHOTO DURING ANY PROGRAM ACTIVITY TO BE USED FOR EDUCATION AND PUBLIC RELATIONS PURPOSES. I FURTHER GIVE CONSENT TO 21ST CENTURY PROGRAM TO SHARE MY CHILD’S RECORDS WITH TEACHERS FOR THE PURPOSE OF ASSISTING MY CHILD ACADEMICALLY, SOCIALLY AND EMOTIONALLY.  I UNDERSTAND WAYNE COUNTY 21ST CENTURY MAY USE MY CHILD’S RECORDS TO EVALUATE INDIVIDUAL PROGRESS AND IMPROVEMENT, AS WELL AS TO EVALUATE THE OVERALL IMPACT OF THE PROGRAM TO OBTAIN FUNDING FOR THE PROGRAM.
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Parent signature *
Date completed *
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