21st CCLC Student Virtual Club REGISTRATION FORM
Please complete the following registration questions/items regarding your student.
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Email *
21st Century Community Learning Center Student Virtual Club Registration Form for Before & After School Programming - Bruner Elementary School
Student Last Name *
Student First Name *
Home Address *
Student ID # *
Birthday *
MM
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DD
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Age *
Grade *
Gender *
1st Choice (Pick One) *
2nd Choice - Alternate - Pick-One
Clear selection
Mother/Guardian Name *
Mother/Guardian Address *
Mother/Guardian Phone Number *
Mother/Guardian Email Address
Father/Guardian Name *
Father/Guardian Address *
Father/Guardian Phone Number *
Father/Guardian Email Address
Emergency Contact #1: Name/Relationship/Phone Number *
Emergency Contact #2: Name/Relationship/Phone Number *
Emergency Contact #3: Name/Relationship/Phone Number *
 Are there any restrictions that are in effect, such as people not allowed to have contact with your student? *
Required
Does your child have any health issues (allergies, medication, asthma, diabetes, epilepsy, etc.) or other related health information that we should be aware of (please explain)? *
Doctor's Name and Phone Number
Preferred Hospital
Does your student receive Special Education services? *
What is your student's ethnicity? *
Student's Homeroom Teacher
Please check one of the following *
Required
Provide additional name(s) of authorized person(s) to sign out or pick up your child. Please include his/her phone number. *
Please read the Policy and Expectations - "3 Strikes, You're Out" Behavior & Attendance Policy
Students will be expected to be RESPONSIBLE, RESPECTFUL & SAFE at all times.  If attendance or behavior is an issue, your child will be removed from the program.  We will utilize a "3 Strikes, You're Out!" policy for behavior, attendance and/or late pick ups.  (Though we will begin with a virtual platform this school year, we want all parents to be aware of ALL pertinent policies up front.)  Anyone who receives (3) "Strike Slips" will be removed and replaced with a child on the Waiting List.  If your child has excessive absences, this will also result in removal from the program.  The 21st Century Grant is closely audited on attendance.  Please be aware that Club participation is a privilege, not an entitlement.
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