Section 1 of 1
Referral Form
The 21st CCLC program provides academic enrichment opportunities during non-school hours. The program helps students meet state and local student standards in core academic subjects such as reading, math, and science in addition to homework help. The program also offers students a broad array of enrichment activities designed to complement their regular academic programs. Enrichment programs are tailored based on student surveys and interest.
If you have a student/child who would benefit from our program, please complete this form.
Student Name
Student Name
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Student Grade
Student Grade
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Time
Ninth
Tenth
Eleventh
Twelfth
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add "Other"
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Your Email
Your Email
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Your Name
Your Name
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Does the student need academic help?
Does the student need academic help?
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Date
Time
Math
Reading
Homework Help
Science
N/A
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add "Other"
…
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What enrichment activities interest the student?
What enrichment activities interest the student?
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Date
Time
Chess Club
Book Club
Interact Leadership Club
Adulting 101
Trivia/Game Club
Other:
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Does the student need help with transition readiness?
Does the student need help with transition readiness?
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Yes
No
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