Extended Learning Program Application 2021-2022

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Please complete one form for each child enrolling in the Extended Learning Program.
The Site Coordinator will contact each parent to confirm enrollment in the program.

Please check the appropriate boxes

Student was in Program last year

Student had siblings in Program last year

If you plan to have more than one (1) child in Program this year

Child's Name (First, Last) *

Birthdate *

YYYY

Age *

Child's address *

City *

Zip *

School Attending *

Child's grade *

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