Rolette 21st Century Extended Learning Program Registration Form
2011-2012

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

            (English, Math, Science)

                                        ___ Elementary Morning Homework Room (K-6/all subjects)

                                        ___ After School Tutoring (K-12/all subjects)

                                         ___Reading Enrichment/LIPS  *By arrangement –Ms. Kunze                               

                                        ___ Art after School  (K-6)

                                        ___ Open Gym (7-12)

                                        ___ Service Projects (Quilts – Grades 5-12)

                                        ___ Signing (K-2)

                                        ___Elementary Enrichment GEMS kit (K-6)

                                        ___ KidsDance(K-6)

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  

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 21^st 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

• Please complete this form for each child and return to the school to Mrs. Walsh
• Please try to complete all information; the more data that I have, the easier it is for me to prove that the 21^st Century money is being spent effectively.