Rockdale Bridges Afterschool Program (Virtual)
21st CCLC Online Application (MEMORIAL)
Student's First Name: *
Student's Last Name: *
Date of Birth: *
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GTID Number (This number is located on the "student summary" page in Infinite Campus) *
Student ID Number (This number is located on the "student summary" page in Infinite Campus) *
Gender: *
Primary Language *
Student's Special Education Status: *
Name of Math or ELA Teacher (also provide teacher's email if possible) *
Age of Student: *
Ethnicity: *
Student Lives With: *
Grade: *
Parent/Guardian's Last Name *
Parent/Guardian's First Name *
Home Address *
City *
Zip Code *
Home Phone#: *
Mother's Cell #: *
Mother's Email Address: *
Father's Cell #:
Father's Email Address:
Siblings (please list)
Mode of Transportation Home *
In the event of an emergency (i.e. inclement weather, sudden closure) how will your child get home? *
Emergency Contact: Name person(s) allowed to pick up your child. List the name, relationship and phone number of the person (Person must show a picture I.D.). *
Is your child under medial care of taking any medications? *
If yes, please list detailed medical needs of the child.
Does your child have an allergies, special needs, or disabilities? If so, please list below.
Does Rockdale Bridges Program have permission to use photos of your child in educational or promotional materials? (No cost) *
I understand that Rockdale Bridges Program is a free afterschool program funded by Georgia Department of Education. By typing your name and date as your electronic signature, I give permission for Rockdale Bridges staff to review my child's academic files for purposes of analyzing program effectiveness and reporting to funding sources. *
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