21st CCLC Summer Enrollment Form
Enrollment for grades 5-12: Please fill out a separate form for each student in your household.
Sign in to Google to save your progress. Learn more
Email *
Student's First and Last Name
Student's Grade Level
Home Address, including city, state, and zip code
Will your student ride the in-town bus route?
Clear selection
Student's E-mail Address
Parent's First and Last Name(s)
Parent's E-mail Address(es)
Student's Phone Number (if applicable)
Parent's Phone Number(s)
Emergency Contact 1 - Name and Phone Number
Emergency Contact 2 - Name and Phone Number
Does your student have health concerns of which we should be aware? Please explain.
Does your student have access to the Internet? Does your child have a computer or iPad at home?
Parent' Signature
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Gurdon Public School District. Report Abuse