21st Century Community Learning Centers Electronic Enrollment Form for Remote Learning
This form is only to be used for students enrolled into the 21st CCLC program that are participating in remote programming only. Students recievig services in person must use the full paper version (available through your Community School DIrector) This form is only valid for 2020-2021 school year.
* Required
STUDENT INFORMATION
Student Name:
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Your answer
Student OSIS (I.D) Number:
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Your answer
School:
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Your answer
Current Grade Level:
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Your answer
Date of Birth:
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MM
/
DD
/
YYYY
Sex:
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Female
Male
Prefer not to say
Other:
Home Mailing Address:
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Your answer
City:
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Your answer
State:
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Your answer
Zip Code:
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Your answer
Home Phone Number:
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Your answer
Student Participant's Email Address:
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Your answer
Racial/Ethnic Group (Optional):
American Indian/Alaska Native
Black or African American
Hispanic of Latino
Asian
White
Pacific Islander
Two or more races
Other
Clear selection
Language(s) Spoken at Home:
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Your answer
Parent/Guardian Information
Name of Primary Parent/Guardian 1:
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Your answer
Guardian Title:
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Mother
Father
Grandmother
Grandfather
Other:
Language(s) Spoken:
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Your answer
Address (if different from student's):
Your answer
Home Phone Number:
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Your answer
Work Phone Number:
Your answer
Cell Phone:
Your answer
Parent/Guardian's Email Address:
*
Your answer
Name of Primary Parent/Guardian 2:
Your answer
Guardian Title:
Mother
Father
Grandmother
Grandfather
Other:
Clear selection
Language(s) Spoken:
Your answer
Address (if different from student's):
Your answer
Home Phone Number:
Your answer
Work Phone Number:
Your answer
Cell Phone:
Your answer
Email:
Your answer
Parent/Guardian Signature Verification - By printing your name here you agree to give your child permission to enroll and participate in the remote 21st Century Community Learning Centers program.
*
Your answer
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This form was created inside of New York City Department of Education.
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