Program Enrollment Form 2021-2022: ELLIS

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Note: The first email address field is used to send you a copy of your enrollment information.

Email *

For more information, please visit www.communitychangeinc.com.

All fields must be completed. Incomplete applications will not be accepted. This enrollment form must be completed and electronically signed by the parent or guardian of the student to be enrolled in the program. Once completed, please click "SUBMIT" at the bottom of the form.

Student's Legal First Name *

Middle Initial

Student's Legal Last Name *

9-digit Student’s I.D. (OSIS) *

Please include numbers only

Student’s Personal Email *

**Cannot be student’s school email account**

Student’s Phone Number *

Must include area code

Student's Date of Birth *

Please format as: 00/00/0000 or 00-00-0000 (Month/Day/Year)

Gender *

Female

Male

Other:

Primary Language Spoken *

Student’s Grade in September 2021 *

Race/Ethnicity *

Student’s school – English Language Learners and International Support Preparatory Academy

Student’s Club – please type the name(s) of the Community Change club(s) the student wishes to attend. Note that the student is expected to attend these clubs each day that they are offered.

Club Name #1

Teacher Name #1

Club Name #2

Teacher Name #2

Club Name #3

Teacher Name #3

Parent/legal guardian involvement in this program is welcomed and encouraged.

Parent/Legal Guardian Name *

Parent/Legal Guardian’s Phone Number *

Must include area code

Parent/Legal Guardian's Email *

Home Street Address (include Apt Number) *

City *

State *

Zip Code *

What are three issues that you are most concerned about in your neighborhood? *

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