21st Century Waiting List (2024-2025) 
This form was developed based on four of the six required goals. 
***Please know that signing up doesn't not guarantee enrollment. 
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Student's Name  *
Has your child participated in the program before? *
Grade for 2024-2024 school year *
I would like for my child to attend:  *
Parent/Guardian Name *
Parent/Guardian Phone #  *
Parent/Guardian Email 
**You will be notified via email of your child's registration in the program. 
 *
Goal 1-Academics
What was your child's MATH average for the 2023-2024 school year? 
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Goal 1-Academics
What was your child's READING/ELA average for the 2023-2024 school year? 
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Goal 2-Parental Involvement
How often are you willing to volunteer with the program? 
 *
Goal 3-Increase Regular School Day Attendance 
Please select the answer that best describes your student's school day attendance for the 2023-2024 school year. 
 *
Goal 6-Student Behavior
Does your child have any steps on the classroom behavior management form or discipline referrals? 
 *
If you answered yes to the question above, please explain. 
 *
What are your expectations of the program? What do you want your student to gain from participating in the 21st Century program? 
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