CCHS 21st Century After-School Virtual Program Registration Form
General registration form for after-school virtual programming
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Student Name
Grade
Student Email Address
Student Birthday
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Home Phone
Parent Cell Phone
Mailing Address
Parent Email Address
All 21st Century Programming is free to students.  We work strictly within a grant budget and will provide programming according to guidelines to assist students in meeting academic standards in core subjects (Math, English, Social Studies, and Science).  We provide out of school time services to students and their families through community learning centers that offer an array of academic and enrichment activities to complement regular academic programs.  Any student in grades 9-12 is eligible to participate in Clinton County 21st Century Program.  We do not discriminate on the basis of race, sex, or religion
I have read and understand the statement above.
What areas you would like your child to work on during 21st Century Programming?
I give my permission for Clinton County 21st Program to take my child’s photo during any programming activity to be used for educational and public relation purposes. I also grant consent to 21st Century Program to share my child’s records with the teachers for the purpose of assisting my child academically, socially and emotionally.  I understand Clinton County 21st Century may use my child’s records to evaluate individual progress and improvement.  In addition, they may use records to evaluate the overall impact of the program to obtain funding for the program.
Clear selection
Parent Signature (type your name in the space below)
Date
MM
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DD
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YYYY
Submit
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