21st Century Community Learning Centers Electronic Enrollment Form for Remote Learning
This form is only to be used for students enrolled into the 21st CCLC program that are participating in remote programming only.   Students recievig services in person must use the full paper version (available through your Community School DIrector)  This form is only valid for 2020-2021 school year.
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STUDENT INFORMATION
Student Name *
Student ID *
School *
Grade *
Date of Birth *
MM
/
DD
/
YYYY
Sex: *
Home Address *
City *
State *
Zipcode *
Home Number *
Student Email *
Racial/Ethnic Group (Optional):
Clear selection
Language *
Parent/Guardian Information
Parent Name *
Guardian Title: *
Language(s) Spoken: *
Address (if different from student's):
Home Phone Number: *
Work Phone Number:
Mobile Number
Parent Email *
Parent Name
Guardian Title:
Clear selection
Language(s) Spoken:
Address (if different from student's):
Home Phone Number:
Work Phone Number:
Mobile Phone Number
Email:
Parent/Guardian Signature Verification - By printing your name here you agree to give your child permission to enroll and participate in the remote 21st Century Community Learning Centers program. *
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