CLC Afterschool Program

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Please complete this form to register your child

Student Name *

Grade *

Parent Name *

Parent Email *

Parent Phone Number *

Emergency Contact 1 *

Phone number *

Emergency Contact 2

Phone number *

Please list any medical concerns *

Will your child need transportation *

yes

If your child will need transportation where will they be dropped off each afternoon? *

If your child is a car rider who is authorized to pick him/her up? Please list all that apply. *

21st Century Community Learning Centers Parent Release of Records and Information Consent Form Virginia Department of Education collects data concerning school related programs throughout the state. The Family Educational Rights and Privacy Act ("FERPA") requires the 21st Century Community Learning Center ("21st CCLC") to obtain prior written consent from the parent, guardian, or eligible student before releasing any personally identifiable information about a student. The information requested will be used to calculate the impact the 21st CCLC has on student performance and to meet reporting requirements as a result of receiving state and federal funds. I understand that this authorization is made pursuant to the Family Educational Rights and Privacy Act ("FERPA"), set forth in 20 USC $1232g and its regulation in 34 CFR Part 99 (as amended in 2012). Furthermore, I understand that this consent is made pursuant to 34 CFR 99.30(a), which requires that (1) the parent or eligible student's consent specify the records to be disclosed, (2) state the purpose of the disclosure, and (3) identify the party or parties to whom the disclosure may be made. By signing this form, I grant the school my student attends permission to disclose to the 21st CCLC the following information. I also grant permission to the 21st CCLC to re-disclose the following information to the re-disclosure parties. 1. Records Disclosure: School Registration Information/Demographic Data, Assessment Data, Student Grades, School Day Attendance, Survey Data, Free and Reduced Lunch Status, Attendance Data Student Grades, Assessment Data, Demographic Data 2. Disclosure Parties: 21st CCLC3. 21st CCLC Re-disclosure Parties: a. Virginia Department of Education b. Colonial Beach Public Schools c. United States Department of Education 4. Purpose of Each Disclosure: Collect data to calculate the impact 21st CCLC has on student performance. All records and information regarding services will be protected by FERPA, which governs the exchange of confidential information. The exchange of information will be limited to the authorized staff of the 21st CCLC and the aforementioned re-disclosure parties. No individual student data will be released beyond that which is specified in this authorization.

Do you give permission to share your child's student records for the purpose of data collection? *

Yes

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