This form is only to be used for students enrolled into the 21st CCLC program that are participating in remote programming only.   Students recievig services in person must use the full paper version (available through your Community School DIrector)  This form is only valid for 2020-2021 school year.
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STUDENT INFORMATION
Student Name *
Student OSIS (I.D) Number: *
School: *
Current Grade Level: *
Date of Birth: *
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DD
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Sex: *
Home Mailing Address: *
City: *
State: *
Zip Code: *
Home Phone Number: *
Student Participant's Email Address: *
Racial/Ethnic Group (Optional):
Clear selection
Language(s) Spoken at Home: *
Parent/Guardian Information
Name of Primary Parent/Guardian 1: *
Guardian Title: *
Language(s) Spoken: *
Address (if different from student's):
Home Phone Number: *
Work Phone Number:
Cell Phone:
Parent/Guardian's Email Address: *
Name of Primary Parent/Guardian 2:
Guardian Title:
Clear selection
Language(s) Spoken:
Address (if different from student's):
Home Phone Number:
Work Phone Number:
Cell Phone:
Email:
Parent/Guardian Signature Verification - By printing your name here you agree to give your child permission to enroll and participate in the remote 21st Century Community Learning Centers program. *
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