JSASD 21st CCLC After-School Program Registration 22-23
Please complete the form below to sign your child up for the 21st CCLC After-School Program at Jersey Shore Elementary School.  The after-school program operates Monday through Friday from 2:30-5:00 beginning on Tuesday, September 6th.  The program is open to any student in grades 1-5 attending Avis, Jersey Shore, or Salladasburg Elementary School.  All students receive an after-school meal and participate in the following activities:  homework help, STEAM, math, ELA, health and P.E.  Free transportation is provided to all students.  There is no fee for the program because it is made possible by a Nita M. Lowey 21st Century Community Learning Centers grant. Please contact Adrienne Johnston at ajohnston@jsasd.org with any questions about the program. 
Sign in to Google to save your progress. Learn more
What is your child's LAST name?  *
What is your child's address?  *
What grade is your child in?  *
What elementary school does your child attend?  *
Parent/Guardian's Name(s) *
Parent/Guardian's Email Address *
Parent/Guardian's Phone Number(s) *
Person to contact in case of emergency *
Emergency Contact's Phone Number(s) *
At 5:00 each day, my child will  *
If you selected "ride a bus," at what address would you like the bus to drop your child off?  *
The following adults have permission to pick up my child from the after-school program:  *
My child has the following allergies:  *
My child has the following health problems:  *
My child has my permission to be photographed during the 21st CCLC After-School Program.  These photographs may be used in local news media or on JSASD social media or website.
 *
Please enter your name in the textbox below. This takes the place of a digital signature, and confirms that this form has been filled out correctly. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Jersey Shore Area School District. Report Abuse
Google Forms