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2021-2022 Extended Learning Program Registration
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student Grade for SY2021-2022
*
PK3
PK4
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Parent/Guardian 1 Last Name:
*
Your answer
Parent 1/Guardian First Name:
*
Your answer
Parent/Guardian 1 Daytime Phone Number:
*
Your answer
Parent/Guardian 1 E-mail Address:
*
Your answer
Parent 2/Guardian Last Name:
Your answer
Parent 2/Guardian First Name:
Your answer
Parent 2/Guardian Daytime Phone Number:
Your answer
Parent 2/Guardian E-mail Address:
Your answer
Emergency Contact (1) Name
*
Your answer
Emergency Contact (1) Phone Number
*
Your answer
My child will attend After School Programming on the following days:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Required
I agree to pay the appropriate fees monthly.
*
Yes
No
I understand that I must complete the NSLP Application for pricing determination -- email it to
info@selpcs.org
.
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No
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