Ivy Preparatory Academy at Kirkwood for Girls 21st CCLC-2018 Summer Program
STUDENT INFORMATION (ALL INFORMATION MUST BE ENTERED. IF NOT, THE APPLICATION WILL BE REJECTED)

The summer parent orientation will be Tuesday May 8, 2018.
Thank You,

Student First and Last name *
Your answer
Does your scholar(s) attend Ivy Prep Academy? (this has no effect on your enrollment) *
Rising Grade (Please check the grade your scholar is going to next year) *
Required
Do they have a sibling that you are also enrolling? *
Please list siblings name and rising grade below ex: (Susan Rogers-7th grade or N/A) *
Your answer
Has your student previously been enrolled in the 21st Century After- School or Summer Program at Ivy Prep? *
Mailing Address *
Your answer
Birthdate *
Your answer
Age *
Your answer
Lunch Status? *
Ethnicity *
Required
Students lives with: *
Medical Restrictions or Concerns: (Please list ALL allergies, medications, specify distribution of medication), Dietary restrictions, etc.) *
Your answer
Check box if legal restrictions are in effect
Parent/Guardian Email Address (Please ensure emails are valid, an acceptance notice or wait-list notice will be emailed to you within 3 business days) *
Your answer
Parent/Guardian First & Last Name *
Your answer
Parent/Guardian Cell Phone Number: *
Your answer
Secondary Contact First & Last Name *
Your answer
Secondary Contact Relationship to child ( mother, father, grandparent, Family Friend) *
Your answer
Secondary Parent/Guardian Cellphone Number
Your answer
Additional Contact First & Last Name (This person is authorized to pick up your scholar in cases of emergency or if scholar is not picked up before dismissal)
Your answer
Additional Contact Contact Cellphone Number (This person is authorized to pick up your scholar in cases of emergency or if scholar is not picked up before dismissal)
Your answer
Additional Contact First & Last Name (This person is authorized to pick up your scholar)
Your answer
Additional Contact Cellphone Number
Your answer
PROGRAM POLICIES
Parents/Guardians, please read each policy carefully.
Student Pick Up- I understand that when I pick up my child, I (or anyone authorized to pick up my child that is 18 years old or older) must sign them out with the 21ST CCLC Staff. Once I retrieve my scholar I should not interrupt the classrooms in any way to ensure student safety and respect the enrichment taking place. Additionally, once my child is signed out they are no longer in the care of the 21st CCLC Program, *
Required
Attendance Policy- I understand that 21st Century requires scholars to not exceed five (5) early pick ups and/or absences. If I can not commit to the attendance policy, I understand my child will be removed from the program. *
I understand the the expectation for good behavior in the 21st Century Afterschool Program. Students who refuse to follow the procedures outlined in the Student Handbook will not be allowed to continue in the program. Parents/Guardians will be contacted if a child misbehaves. Chronic misbehavior may result in dismissal from the program. *
Required
FIELD TRIP APPROVAL
Parents will be notified prior to these events. I give permission for my child to participate with the 21st Century Field Trips and activities. I release Ivy Prep Academy at Kirkwood for Girls and the 21st Century Program from any liability in the unlikely event of an injury or accident. *
TRANSPORTATION *
Signatures
By your signature on this document, you hereby agree and consent that your child may participate in the 21st Century Community Learning Centers Program. You have been informed of the policies and procedures of the program, and understand that no medical expenses will be paid in connection with any injury incurred while participating in the activities of this program.
Name of Parent/Guardian: (By typing your name below, this serves as your signature for the above statement.)
Your answer
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