Chestnut Log Middle School 21st CCLC Summer Camp Registration Form

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Summer Camp Program

Greetings Parents and Guardians,

Please complete this form if you are interested in your child(ren) attending our summer camp program. We will be hosting a variety of activities (ELA, Math and STEM) and off campus field trips (3). The camp will fill up fast and is first come, first serve. If you have any question, please let me know.

CLMS 21st CCLC Summer Camp Information

Location: Chapel Hill Middle School

Dates: June 3 - 18, 2024 Monday through Friday

Time: 8:30am to 1:00pm

21st CCLC Coordinator: Mikki Lucas

Email: mikki.lucas@dcssga.org

Phone: 770-651-5232

ESOL Contact: Angelic Seely

Email: angelic.seely@dcssga.org

Phone: 770-651-5127

Email *

“Creating Excellence Together”

Student First Name *

Student Last Name *

Student Current Grade Level *

6th

7th

8th

Please select the one that applies to your student below. *

My student is an ELL (English Language Learner) or part of the ESOL program.

My student is NOT an ELL.

Parent(s)/Guardian(s) Name *

Parent(s)/Guardian(s) Phone Number *

Please select transportation to and from the program *

Car Rider

Bus Rider

Both

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