21st Century Application
LAST name of student *
FIRST name of student *
What school does your child attend? *
Student Grade *
Parent Name(s) *
Homeroom Teacher *
Home Phone
If applicable, with area code please.
Home Address *
Street Address/ City/ Zip Code
Mother's Work Phone
If applicable, with area code please.
Mother's Cell Phone
If applicable, with area code please.
Father's Work Phone
If applicable, with area code please.
Father's Cell Phone
If applicable, with area code please.
Who do we contact in case of emergency? *
Name, relationship and phone number.
List anyone who has permission to pick your child up from the after school program.
Please include phone number.
List anyone who has permission to pick your child up from the after school program.
Please include phone number.
List anyone who has permission to pick your child up from the after school program.
Please include phone number.
List any medical concerns of which we need to be aware. *
If none, please list "none".
PROGRAM NOTICE *
The selection process for applicants will be based on specific criteria and focused on academic need. This process will begin immediately, so applicants are encouraged to turn in their applications as soon as possible. After selections are made, all applicants will be notified. Those who are not selected will be placed on a waiting list and may be notified as slots become available. "I give permission for my child to participate in the 21st Century Community Learining Center at my child's school. I understand that if a discipline problem arises, I will be notified to come to school and pick up my child. I understand that the program runs Monday-Thursday, 3:00-5:30PM, and that I will be expected to pick up my child no later than 5:30PM daily. I also understand that if there are persistent discipline or attendance problems my child will not be allowed to attend." Please list the last 4 digits of your social security number to serve as your electronic signature.
Submit
Never submit passwords through Google Forms.
This form was created inside of White County Schools. Report Abuse