Alcovy EOC 2023-2024 21st Century Registration Form
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Student's Last Name *
Student's First Name *
Student's Date of Birth *
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Gender *
Lunch Status *
Student's Race *
Student's Primary Language *
Home Address *
City *
State *
Zip Code *
Student's Telephone Number
Grade *
Who does student live with? *
Does student receive Special Education Services with Newton County School System? *
Parent/Guardian Name *
Parent/Guardian Email Address *
Parent/Guardian's Telephone Number *
Is parent/guardian English proficient? *
Does your child have any food allergies? If yes, please list them.
Emergency Contact Name *
Emergency Contact Telephone Number *
Does your child need transportation home? (MIDDLE & HIGH SCHOOL ONLY) *
Please list the address of their drop-off location. (Must be within the school zone) *NOTE: There is NO door to door drop-off. Students will be assigned a drop-off point. *
T-shirt size *
Is your child involved in any other afterschool activity? If so, please list the activity/activities. *
Parent/Guardian Signature (by typing my name below, I am confirming that this information is true and accurate. I am also giving permission for my child to participate in the 21st CCLC program with Newton County School System and be photographed for reporting and evaluation purposes). PLEASE TYPE YOUR NAME *
Date signed *
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