(2018 - 2019) SETLC/RWLC - 21st CCLC Afterschool Program
Winter Program Session begins Monday, January 7, 2018
Email address *
Please confirm your scholar will attend at least 3 days a week. *
Scholar's First Name *
Scholar's Last Name *
Grade *
Scholar's Age (Please note: All scholars participating in the afterschool program, must scholar must be in Grade 2 and 7 years old.
T-Shirt Size *
Address *
City *
State *
Zip Code *
Ward *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Required
Race/Ethnicity *
Required
Current School *
Type of School *
Required
Does your child struggle with a particular subject?
If yes, please select the subject
Does your child receive: *
Required
Parent's/Guardian's Name *
Relationship to Student *
Required
Home Phone *
Cell Phone *
Work Phone *
Email Address *
Emergency Contact Person *
Relationship to Scholar *
Home Phone *
Cell Phone *
Email Address *
Work Phone *
Name of Scholar's Physician *
Physician's Phone Number *
Medical Insurance Company/Policy Number *
Does Your Child have allergies or other health factors of which we should be informed? *
Required
If yes, please explain *
Does your child take any daily medication? Please provide an explanation *
Has your child participated in any SETLC program before? *
Required
If Yes, When? *
Authorized Pick Up Person #1 *
Relationship to scholar
Cell # *
Authorized Pick Up Person #2 *
Relationship to scholar *
Cell # *
Authorized Pick Up Person #3 *
Relationship to Scholar *
Cell # *
I understand that my application may not be processed until ALL documentation has been submitted and the Activity Fee of $50.00 per session, in the form of Money Order or Cashier's Check has been collected? *
Required
Please upload the following documentation (Latest Report Card, Test Scores, Proof of DC Residency - Driver's License or Identification Card, Voter's Registration and Car Registration)
Submit
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