Rolette 21^st 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 – 12 Science tutoring/homework help

                                         ___ After school tutoring/homework help

                                         ___ Reader’s Theater (K-2)  TBA

                                         ___ Reader’s 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 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.
• FOR AFTER SCHOOL TUTORING: If you know you are going to be late picking students up, please call the school (701 246 3595) and let the After School Monitor know that you will be late.  If you are more than 10 minutes late without calling more than twice, your child may not be able to participate in this activity. I hope that this will not have to happen as I want each child to be able to participate in 21^st Century Activities.