Clarkston Community Center QUIET ZONE
This is a registration form for our in-person learning space for elementary, middle & high school students participating in virtual schooling. Before filling out this application, you MUST be a resident of DeKalb County.

Grade levels that are eligible: 3rd grade - 12th grade


Monday & Tuesday 8:30am-2pm
Thursday 8:30am-2pm

*For students that have late pick-up, parents will have to pay a $1 fee for every minute after 2pm.
Email address *
Parent Full Name *
Country of Origin *
Parent Contact Info (Email & Phone Number) *
Emergency Contact Full Name *
Relationship to Student *
Emergency Contact Phone Number *
Student Full Name *
Grade Level *
Name of School *
Does your school conduct in-person, virtual, or hybrid (in-person & virtual) schooling? *
What virtual platform does the school use? *
If you HAVE NOT been tested for COVID-19, please contact the Clarkston Community Health Center to schedule your appointment today by calling 678-383-1383.
Has the student been in contact with anyone with COVID-19 in the past 14 days? *
Has the student taken a COVID-19 test in the past 14 days? *
Has the student tested negative? *
Does the student have food allergies or food restrictions? *
If you answered yes to the question above, please state what food allergies or dietary restrictions those are? *
Does your child require any special needs? *
If you answered yes to the question above, what are they? *
Does your child require any daily medication (EpiPen, inhaler, etc.) that will need to be kept on-site? *
If you answered yes to the question above, what medication must student take? *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Clarkston Community Center. Report Abuse