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WKC Distance Program Registration 20-21
This form will be used as your student's registration for the distance program offered at Willits Kids Club
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* Indicates required question
Email
*
Your email
Student Name- First and Last If you have more than one student attending, please fill out separate forms for each student.
*
Your answer
Grade Level
*
Choose
6
7
8
Guardian Name First and Last
*
Your answer
Contact Numbers
*
Your answer
Are interested in receiving craft and activity materials through WKC? (They will be delivered.)
*
Yes
No
Are you interested in your student receiving virtual academic and enrichment support?
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Yes
No
Does your child need academic help?
*
Yes
No
How has school been going for your student? How can we support your student during distant learning? What challenges have you been facing?
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Your answer
Are there any program suggestions or other needs that you would like to make us aware of?
*
Food
Housing
Education Support
Mental Health Services
No
Other:
Required
Type your Initials as a signature for this form
*
Your answer
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This form was created inside of Willits Unified School District.
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