LMS 21st CCLC "RESPECT" 2021-2022 Student Registration Form
Morning Remediation (7:30-8:30 AM)        After School (3:30-5:30 PM)
This form must be completed with the assistance of a parent or a guardian in order to be able to participate in the program in person and/or virtual.
*Required
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Email *
Student Name (First, Middle, Last) *
Grade Level *
Required
Gender *
Racial Category *
Date of Birth *
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Parent/Guardian Full Name *
Parent/Guardian Email Address
Mailing Address- Example: Daffy Duck PO Box 12345, Lebanon, VA 24266 *
Physical Address- Example: Daffy Duck 789 Yellow Rd, Lebanon, VA 24266 *
Detailed directions from LMS to home *
Home Phone Number *
Regular Bus Number- If student doesn't ride bus, just type "NA" *
Student will be picked up? *
Student has permission to ride with the following adults. Please be specific-Example: Mickey Mouse, uncle, phone number *
Existing Medical Conditions (be specific). Enter "None" if there are no existing medical conditions. * *
Emergency Contact Name, Relationship to Student, and Phone Number. *
Emergency Contact Name, Relationship to Student, and Phone Number. *
Emergency Contact Name, Relationship to Student, and Phone Number. *
I (parent/guardian) authorize my child to participate in ALL activities and local (Lebanon area) field trips associated with the RESPECT 21st CCLC program.  I understand that he/she will travel by bus or walk to some events.  Students are responsible for notifying parents/guardians of the details of the trip. Students will return to school in time to ride the regular After School transportation home. *
I authorize staff of the 21st CCLC RESPECT program to take pictures/videos/record online sessions of my child during special events and projects. I authorize the program staff to use these pictures/videos in program newsletters, flyers, news releases, promotional materials, school/district social media accounts, and websites. * *
(Enter Student Name Below) has my permission to participate in the 21st CCLC RESPECT Before School and/or After School programs at Lebanon Middle School. * *
Parent/Guardian name giving permission to participate in the 21st CCLC RESPECT morning remediation and/or After School programs. **The parent's name serves as an electronic signature. * *
Today's Date *
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To help with the planning of the RESPECT Morning Remediation and After School program at Lebanon Middle School, please indicate activities that you would like to see your child involved in during the upcoming school year.                   *
Required
We want to offer parents/guardians training, educational sessions, fitness sessions, field trips, guest presenters, and more! Please help us plan our program with activities and field trips that would interest you! *
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