Rolette 21st Century Extended Learning Program Registration Form 2012-2013

 

 

Name___________________________________Birth date-mm/dd/yy______________

 

Grade_______Date Enrolled-mm/dd/yy__________

 

Will be attending:       *Check all programs that your child is interested in attending.

     ___ High School Morning Homework Room

                                         ___ Elementary Morning Homework Room

                                         ___ Morning 7 Ė 12 Science tutoring/homework help

                                         ___ After school tutoring/homework help

                                         ___ Readerís Theater (K-2)  TBA

                                         ___ Readerís Theater (3-6)  TBA

                                         ___ Art after School  (K-2)

                                         ___ Art after School (3-6)

                                         ___ Open Gym (7-12)                                                                        

                                         ___ Service Projects (Quilting)

                                         ___Elementary Enrichment GEMS kit (K-1)  TBA

                                         ___Elementary Enrichment GEMS kit (2-3)  TBA

                                         ___Elementary Enrichment Gems kit (4,5,6) TBA

 

Parent/Guardian (1)______________________________________________________

 

Address________________________________________________________________

 

Home #____________Work #___________Cell #___________email_______________

 

Parent/Guardian (2)______________________________________________________

 

Address________________________________________________________________

 

Home #____________Work #___________Cell #___________email_______________

 

Transportation:

How will your child be picked up after school?

( )Permission to walk home alone      ( )Picked up by parent/guardian

( )Permission to walk home with sibling 

 

Child May Be Picked Up By:

 

Name_______________________Relation______________Phone_________________

 

Name_______________________Relation______________Phone_________________

 

Child May NOT Be Picked Up By:Name_____________________Relation__________

 

Miscellaneous:

( )Allergies____________________( )Medicine________________________________

 

Required 21st Century Community Learning Center Information:

 

Gender: ( )Male  ( )Female 

 

 Ethnicity: ( )American Indian/Alaska Native   ( )Asian/Pacific Islander

  ( )African American ( )White  ( )Hispanic or Latino

 

Special Service or Programs:

( )Limited English proficiency  ( )Special needs  ( )Special Education   ( )IEP

( )Eligible for free or reduced-price lunch