Registration for 21st CCLC Programs 2021-22
Please register here to participate in any 21st Century Community Learning Center program.   Please check any and all activities your student might have interest in. * Participants, families, and staff:  Compliance with all expected BCPS mitigation strategies is a requirement for participation and operations. Students who do not comply will be removed and staff who do not execute plans will be subject to administrative reprimand.
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Student's School email address (example: 2022basmith@bedford.k12.va.us) *
Student Name *
Student 7-digit ID/lunch # *
Student attends: *
2021/2022 grade level *
Parent Contact Name (This will serve as an electronic parent signature, indicating permission to participate in virtual and remote learning) *
Home Phone *
Parent Contact Cell Number *
Work Phone *
Parent Email Address that you check regularly *
Mailing Address:  Please complete city and zip in questions below. *
City: *
Zip Code *
Please list any health needs or special accommodations that we need to be aware of; If none, please type "none". *
Student Date of Birth *
Math Teacher *
English Teacher *
Emergency contact if parent/guardian cannot be reached in an emergency situation: Name and phone # *
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