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BHS Summer Programming 2022 and                          21st Century CLC Information Form
Completion of this form does not guarantee acceptance into the program * Program is free to all program participants.
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21st Century CLC/Sylvan Learning
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Student Name (First, Middle, Last) *
Birthdate: *
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Age:   *
Sex:   *
Race Ethnicity:  Check all the apply *
Required
Home or Cell Phone #: *
Home Address:  Street, City, Zip Code *
Grade:   *
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name(s):   *
Home Phone #: *
Parent Cell Phone #:   *
Work Phone #: *
Address (if different from child(s):  Street, City, Zip Code:   *
Email Address:
My child will be: *
Required
I would like to receive 21st Century E-News and Updates Using Email Address Above:
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EMERGENCY CONTACT INFORMATION
Emergency Contact #1 Name *
Relationship to Child: *
Home Phone # *
Cell Phone # *
Work Phone# *
Emergency Contact #2 Name *
Emergency Contact #2 Relationship to Child *
Home Phone # *
Cell Phone # *
Work Phone # *
Name of Physician (or clinic) and Phone Number *
Name of Insurance Provider and Policy Number
Hospital preferred for emergency medical treatment *
PARENTAL CONSENT FOR THE FOLLOWING ITEMS:
Does your child have health concerns that program staff should be aware of? (Please include allergies, restrictions, etc.) *
Does your child have any EMERGENCY MEDICATION at school that we should be aware of?  (Be sure that the proper forms are in place to allow our staff to give these medications to your child) *
Are there activities your child should not participate in? (list) *
May program staff apply sunscreen, insect repellant and general first aid while participating in 21st Century programs? *
May program staff photograph, videotape, and interview your child for program promotion, recognizing that this information may be used on the web, television, radio, and in print? *
Required
Are your child's immunizations current, and is he/she in good health? *
Are your child's immunizations (or appropriate waiver) record on file with the school? *
I hereby certify that by completing and signing this form, it is with my full knowledge and consent that my son/daughter may participate in the 21st Century Programs. I am aware that this 21st Century CLC will maintain a notebook of licensing inspection and special investigation reports and related corrective action plans for the last 5 years. This notebook will be available to me during hours of operation. I can also find reports from  the  past three years on the licensing website at www.michigan.gov/michildcare.  I understand that 21st Century and its contracted providers may use ethnic background data and student records, and that my child's teachers/school district may share student records including grades, standardized test scores, attendance and discipline, etc. information for evaluation purposes. Health information on file with the school may be released in order to secure emergency medical treatment. I understand the playground equipment may or may not comply with guidelines in the 1997 Handbook for Public Playground Safety. I will attend parent/family events and communicate with staff as necessary to address my child's needs. Please add parent/guardian signature below verifying that all information is accurate.   *
Today's Date: *
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