21st CCLC Summer Enrollment Form
Enrollment for grades 5-12: Please fill out a separate form for each student in your household.
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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?
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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.
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