Winter/Spring Registration 2020-21
Please register here to participate in any 21st Century Community Learning Center program.
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Student's School email address (example: *
Student Name *
Student attends: *
2020/2021 grade level *
Parent Contact Name (This will serve as an electronic parent signature, indicating permission to participate in virtual and remote learning) *
Parent Email Address that you check regularly *
Parent Contact Number *
Mailing Address, including address, city, state, zip code *
Please list any health needs or special accommodations that we need to be aware of: *
Student Date of Birth *
Math Teacher *
English Teacher *
Parent/Guardian Names *
Home Phone *
Cell Phone *
Work Phone *
Emergency contact if parent/guardian cannot be reached in an emergency situation: Name and phone # *
There will be no 21st Century Grant transportation provided this year.  Student must provide own transportation to CVCC or other class locations. My child will... *
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