Belleview Middle School 21st CLCC Application
All Parents/Guardians,

We are pleased you have shown an interest in signing your child up for our 21st CCLC AfterSchool Program.  We look forward to working with you and your child over the course of the program and will provide an educational, fun and safe environment.   This form must be filled out for each child that you are applying for.  

Please answer all questions below.  Remember, just by submitting this form does not guarantee admission to the program.  Please note, your child must be an enrolled student here at BMS BEFORE you can apply to the 21st CLCC program.  You will receive an email with confirmation.  You will also receive a separate email confirming if your child qualifying for the limited bus schedule.  

By entering your name at the bottom of this form you are confirming you and your child will follow all policies, statements, and responsibilities of the BMS 21st Century Program.  Furthermore, you understand the 21st CCLC program adapts its policies and procedures from the Marion County Public Schools’ Code of Student Conduct and you agree to comply with the contract and to adhere to policies and procedures within the Code of Student Conduct.  

Thank you and I look for to working with you and your child/children.  

Sincerely,
Lori Root
BMS 21st Coordinator  

Thank you for providing this information for Marion County Public Schools-21st  CCLC program. Please remember ALL data is kept strictly confidential as required by 21st CCLC and only used for data gathering purposes.
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Student full name *
Marion County Student ID *
Current 21/22 School Grade *
Which session are you interested in for your child? *
How will the student get home from the PM program? *
If attending the PM session, is your student needing to attend for any of the following: *
Required
Child's Date of Birth (MM/DD/YYYY) *
Child's Gender *
Child's Home Address, Including City, State, and Zip *
Parent/Guardian #1 Contact Name and Phone Number during the hours of operation *
Parent/Guardian #2 Contact Name and Phone Number during the hours of operation *
Parent/Guardian Email address (you may list more than one) *
Please check the most appropriate Household Composition: *
Total Number of Adults in Household? *
Total Number of Children in Household? *
I am aware that this 21st CCLC After-School Program application submission is for Belleview Middle School ONLY. *
I give permission to 21st CCLC Program to use said photos/videos of my student, family and myself to be use... *
I understand that in order for this program to meet grant requirements, attendance and participation is mandatory. *
I understand that my child is required to attend at least half of the duration of the program, until 5:10 PM before being checked out early. There will be no check outs after 5:45 PM.  (After 5:45 adults are to stay in carline until students are walked out as one.) *
I understand that this is an academic and personal enrichment program and not childcare. *
I understand participation in this program is voluntary and at any time I may choose to withdraw my student(s). *
Required
The program provides designated times for instruction, enrichment activities, and homework. During homework time, staff is available for assistance. Though reasonable effort will be made, staff is... *
I understand my child is not allowed to leave a 21st Century site unless picked up by an authorized adult. *
I understand that my child must be picked up no later than 5 minutes after dismissal. *
I understand a written Incident and/or Behavior Report will be completed and discussed with me whenever my child behaves disrespectfully or improperly, uses improper language, or in any way disruptive... *
I understand at least one parent/guardian will be required to attend Adult Family Literacy meetings in order to stay in compliance with grant requirements. *
I understand no personal electronics of any kind are permitted to be used during program hours, this includes phone calls with parents during program time.   (Students may use the discipline phone to call home if a need arises.)  21st Century cannot be held responsible for loss or damage to any electronic devices. *
I am certifying that the above information is true and complete to the best of my knowledge. Parent/Guardian Signature (Please type your full name) *
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