Clarkston Community Center QUIET ZONE
This is a registration form for our in-person learning space for elementary, middle & high school students participating in virtual schooling. Before filling out this application, you MUST be a resident of DeKalb County.

All grades eligible. Behavioral conduct will be taken into consideration.

SCHEDULE:

Monday & Tuesday 8:00am - 3pm
Thursday 8:00am - 3pm

*For students that have late pick-up, parents will have to pay a $1 fee for every minute after 3pm.
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Parent Full Name *
Country of Origin *
Parent Contact Info (Email & Phone Number) *
Emergency Contact Full Name *
Relationship to Student *
Emergency Contact Phone Number *
Student Full Name *
Grade Level *
Name of School *
Each day, what time does your student(s) start and stop school? *
Does your school conduct in-person, virtual, or hybrid (in-person & virtual) schooling? *
What virtual platform does the school use? *
If you HAVE NOT been tested for COVID-19, please contact the Clarkston Community Health Center to schedule your appointment today by calling 678-383-1383.
Has the student been in contact with anyone with COVID-19 in the past 14 days? *
Has the student taken a COVID-19 test in the past 14 days? *
Has the student tested negative? *
Does the student have food allergies or food restrictions? *
If you answered yes to the question above, please state what food allergies or dietary restrictions those are? *
Does your child require any special needs? *
If you answered yes to the question above, what are they? *
Does your child require any daily medication (EpiPen, inhaler, etc.) that will need to be kept on-site? *
If you answered yes to the question above, what medication must student take? *
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