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2023-2024 LSHS
21
ST
CENTURY COMMUNITY LEARNING CENTER
STUDENT REGISTRATION FORM
Lithia Springs High School SOAR Program
For Questions: Please call 770-651-6835 or althea.elliott@dcssga.org / 770-651-6727 or treena.edwards@dcssga.org
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* Indicates required question
STUDENT FIRST NAME
*
Your answer
STUDENT LAST NAME
*
Your answer
GENDER
*
Female
Male
DATE OF BIRTH
*
MM
/
DD
/
YYYY
AGE
*
Your answer
GRADE
*
Freshman
Sophomore
Junior
Senior
LUNCH STATUS:
(CHECK ONE)
*
FREE/REDUCED
PAY IN FULL
ETHNICITY:
(CHECK ONE)
*
AMERICAN INDIAN/ALASKAN NATIVE
ASIAN
BLACK
HISPANIC
NATIVE HAWAIIAN
OTHER PACIFIC ISLANDER
OTHER/UNKNOWN
WHITE (NOT OF HISPANIC ORIGIN)
PRIMARY LANGUAGE:
(CHECK ONE)
*
ENGLISH
SPANISH
OTHER
STREET ADDRESS
*
Your answer
CITY
*
Your answer
STATE
*
Your answer
ZIP CODE
*
Your answer
HOME PHONE#
*
Your answer
CELL PHONE#
*
Your answer
WORK PHONE#
*
Your answer
PARENT EMAIL
*
Your answer
TRANSPORTATION
:
*
ASP
BUS
CAR RIDER
SPECIAL EDUCATION
*
Yes
No
LIVES WITH
:
*
BOTH PARENTS
FOSTER CARE
GRANDPARENTS
JOINT CUSTODY
SINGLE PARENT (FATHER)
SINGLE PARENT (MOTHER)
OTHER
ALLERGIES:
IF NO, TYPE NONE.
IF YES, PLEASE LIST:
Your answer
DO YOU HAVE OTHER CHILDREN IN YOUR HOUSEHOLD PARTICIPATING IN THE 21
ST
CCLC GRANT? IF NO, TYPE NONE.
(
IF YES, PLEASE LIST NAME AND SCHOOL
)
*
Your answer
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