21st CCLC EXPLORE Extended Day Enrichment Program
This is an application for EXPLORE Extended Day Program for the 2018-19 School Year
Email address *
School student is attending in the 2018-19 School Year *
Grade of child during the 2018-19 school year *
Student Full Name *
Your answer
Gender
Date of Birth
MM
/
DD
/
YYYY
Home Address
Your answer
Area Code:
Your answer
Home Phone
Your answer
Work/Cell Phone
Your answer
Parent/Guardian Name:
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Parent/Guardian's email address *
Your answer
Secondary Contact
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Secondary Contact's email address
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In the event parent/guardian cannot be reached please list relationship/phone number of individuals to call:
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Transportation( please check wether your child will require bus transportation or will be picked up.)
MEDICAL INFORMATION Allergies (please check all that apply and list any additional): Food *
Required
Please list all dietary restrictions that your child may have- this includes religious dietary restrictions:
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Please list any accommodations that your child will require due to religious beliefs:
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Check all that apply *
Required
Agency Contact Information
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Reading Hours
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Emergency Medical Information
Contact Person
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Contact's Home Phone Number
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Contact's Work Phone Number
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Contact's Cell Number
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Doctor's Name
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Doctor's Phone Number
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Preferred Hospital
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Release Information
My child may be released to the following person(s) provided they present acceptable identification.
Name and Address of Person Child Maybe Released To *
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Relationship to the Child
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Name and Address of Person Child Maybe Released To
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Relationship to the Child
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I HEREBY GIVE MY CHILD PERMISSION TO PARTICIPATE IN ALL ASPECTS OF THE EXPLORE PROGRAM:
I certify that I am the above-named parent/guardian of
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and, as such, do hereby give my consent for his/her enrollment and daily attendance in the EXPLORE PROGRAM, in accordance with the program policies and that my child will attend every day. Please put your full name and date. *
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Days During the Week Available
When on the above days?
A copy of your responses will be emailed to the address you provided.
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