Q3 Student Registration Packet
Congratulations! Your child has been accepted into Club21c! We are so excited to see your child grow academically and through their passion! Please complete this survey to officially enroll your child into Club21c! If you have any questions about enrollment or the program, please contact Stacey Buus (stacey.buus@boone.kyschools.us) Heather Smith (heather.smith@boone.kyschools.us)

**Information collected here is for data analysis purpose as well as contact information for the program. All information is confidential. **

Student's First Name *
Your answer
Student's Last Name *
Your answer
Ethnicity
Is there another language spoken at home besides English? *
Other languages spoken at home
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Grade Level *
Homeroom Teacher *
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