21st CENTURY COMMUNITY LEARNING CENTER
REGISTRATION FORM
2011-2012
NAME ___ ______ Date of Birth __ / _ / GRADE ADDRESS ________ _____ PARENT/GUARDIAN (print) _______ _______ PHONE ______________ WORK/CELL _____________
E-mail _________________
TEACHERS: Math _____ Homeroom___
GENDER ( ) Male ( ) Female LUNCH STATUS ( ) Free ( ) Reduced ( ) Full
PRIMARY LANGUAGE ETHNICITY
LIVES WITH: ( ) Both Parents ( ) Grandparents ( ) Guardian ( ) Single Mother ( ) Single Father ( ) Foster Care ( ) Other
SPECIAL NEEDS (allergies, medications, diet, etc) ____________________
EMERGENCY CONTACTS/PICK-UP LIST
NAME PHONE ____ RELATIONSHIP _________ ________ _______
PARENTS SIGNATURE DATE