FY25 - 21st Century CLC Registration           
21st Century CLC Program is only open to students who attend the 21st Century Community Learning Centers Site during the regular academic school year. Please complete this form for your child (ren).
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Student 's Last Name *
Student 's Middle Name *
Student 's First Name *
Student's Date of Birth   *
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Student 's Street Address *
City *
Zip Code *
 Telephone Number (Including Area Code) (No Symbols) *
 Current Grade (2024-2025 School Year) *
 Which 21st Century CLC Site will your child attend? *
What is your child(ren) Mode of Transportation? *
Teacher's Name (Homeroom Teacher - First and Last Name) *
 Special Needs - allergies, medications, diet, etc.      (Type N/A if not applicable) *
Student's Gender *
Lunch Status *
Student Lives with *
Student's Ethnicity *
Primary Language *
Total number of students you are registering: *
First & last names of ALL students in your household you are registering. *
 1st Parent/Guardian Last Name *
 1st Parent/Guardian First Name *
 1st Parent - Relationship *
  Does the student live with 1st parent/guardian? *
 1st Parent/Guardian Home Phone *
 1st Parent/Guardian Work Phone *
 1st Parent/Guardian - Best Email Address *
2nd Parent/Guardian Last Name (Type N/A if not applicable) *
2nd Parent/Guardian First Name (Type N/A if not applicable) *
2nd Parent/Guardian - Relationship *
Does the student live with 2nd parent? *
  2nd Parent/Guardian Home Phone  (Type N/A if not applicable) *
  2nd Parent/Guardian Work Phone  (Type N/A if not applicable) *
  2nd Parent/Guardian Best Email Address *
 Additional Contact - Last Name (Type N/A if not applicable) *
 Additional Contact - First Name (Type N/A if not applicable) *
 Additional Contact - Relationship (Type N/A if not applicable) *
Does the student live with the person? *
Additional Contact - Home Phone *
Additional Contact - Work Phone *
I agree to participate in the Community Learning Center (CLC) programs and activities and I hereby give permission for the participant(s) listed above to take part in the School District's 21st Century Community Learning Centers (CLC) activities, which may include off-site events, academic assistance, continuing education, and recreational programs. *
Required
I hereby give my consent to the School District's 21st Century Community Learning Centers (CLC) programs to take the participant's photograph during program activities, to be used for education and public relations purposes in conjunction with the School District's 21st Century Community Learning Centers (CLC) programs. *
Required
I hereby give permission for my child's artwork, poetry or other work produced in conjunction with the School District's 21st Century Community Learning Centers (CLC) programs to be used for education and public relations purposes *
Required
I understand that the information to be posted may include information from my child's academic, guidance, permanent or cumulative record (i.e. grades or attendance records). I also understand that the information to be posted does not include other personal identifiable information such as my child's address, phone number, or social security number. *
Required
I further give my consent to the School District and the 21st Century Community Learning Centers (CLC) to share the participant's student records with each other for purposes of providing educational support and assistance. *
Required
I understand that the School District will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on student achievement and to obtain continued funding for the program. *
Required
I hereby certify that I have read and do understand the above information. *
Required
Typing my name here certifies this form and indicates the authorization of my child's participation in the 21st Century CLC 2024-25 In-Person Program. Print Parent/Guardian First and Last Name *
Today's Date: *
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