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CHS 2022-2023 21st CCLC Student Sign-Up
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* Indicates required question
STUDENT EMAIL (SCHOOL)
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Your answer
STUDENT LAST NAME
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Your answer
STUDENT FIRST NAME
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Your answer
STUDENT Address
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Your answer
PARENT/Guardian Name (First and Last)
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Your answer
PARENT/Guardian Cell Phone
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Your answer
PARENT/Guardian Email
*
Your answer
Additional PARENT/Guardian Phone
*
Your answer
EMERGENCY CONTACT (not listed above) Name (First and Last)
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Your answer
EMERGENCY CONTACT (not listed above) Phone
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Your answer
EMERGENCY CONTACT (not listed above) Relation to Student
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Your answer
Transportation:
Please mark only one and consider this to be your primary mode of transportation.
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My student will need to ride the bus home (may take 3-4 days to process) (alternate transportation my be necessary until a "bus slip" has been issued)
My student will be picked up by parent/guardian (please be advised students MUST be signed out at the front office is picking up before 5 pm)
My student will drive themselves home (please send written note giving permission for driving AFTER the 3 pm dismissal) (Student cannot sign themselves out (if under 18) and must still have permission to leave before 5pm)
My student will walk home (please send written note giving permission for walking home AFTER the 3 pm dismissal) (Student cannot sign themselves out (if under 18) and must still have permission to leave before 5pm)
Student's medical conditions and/or allergies (if none, enter NONE)
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Your answer
Student's Physician and phone number
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Your answer
Do you giver permission for your child to be photographed?
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yes
no
Choose a MORNING class (7 am).
Choose only 1 option.
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Academic Assistance
Fitness Program
My student will not be attending in the morning
Required
Choose which MORNINGs your student will attend
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Monday
Tuesday
Wednesday
Thursday
Friday
NA (my student will not be attending mornings)
Required
Choose an AFTERNOON class (3:30 pm - 5:10 pm). A super snack will be served from 3:15 - 3:30 PM each day in the cafeteria.
Choose as many as applies. (IF student is known to be failing 2 or more classes and/or known to have missing assignments in ANY class, they will be placed in Academic Assistance until this deficit is resolved.)
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Academic Assistance
RTI Math
RTI ELA
Fitness Program
Marksmanship (must be enrolled in JROTC)
My student will not be attending in the afternoon
Robotics Club (must be a member)
Required
Choose which AFTERNOONSs your student will attend
*
Monday
Tuesday
Wednesday
Thursday
Friday
NA (my student will not be attending afternoons)
Required
Submit
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