Please complete this form if you are registering for 21st CCLC 2020-2021 Programs.  Complete one form for each child.

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* 1. Select your child's 2020-21 school.

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* 2. Enter your child's student ID.

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* 3. Enter your child's first and last names.

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* 4. Select your child's gender.

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* 5. Select your child's ethnicity.

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* 6. Enter your child's age and date of birth.

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* 7. Enter your child's 2020-21 homeroom teacher.

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* 8. Select your child's 2020-21 grade.

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* 9. Select the category for the parent/guardian your child lives with.

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* 10. Enter your full name as the parent/guardian of this student.

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* 11. Enter your mailing address

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* 12. Enter your contact phone numbers.
These numbers must be current in case there is an emergency situation with your child.

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* 13. Enter your e-mail address.

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* 14. Please provide emergency contact information for someone other than the parent/guardian

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* 15. Select the relation of the provided emergency contact above.

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* 16. List any allergies or medical conditions for your child.

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* 17.
I understand that the expectations for good behavior in the 21st CCLC 2020-2021 Programs are the same as during the regular school day.  All regular school day rules apply during the 21st CCLC 2020-2021 Programs, including dress and behavior rules.  Students who refuse to follow these procedures will not be allowed to continue in the program.  Parent(s)/Guardian(s) will be contacted if a child misbehaves.  Chronic misbehavior may result in dismissal from the program.

I understand and agree to the evaluation process for participants and parents, which include surveys and access to student records.  These instruments are used to evaluate the academic progress of participating students.  In addition, student and parent interviews are needed to determine what impact the program is having and to implement necessary changes in the program.

I have read and understand the guidelines above for the 21st CCLC 2020-2021 Programs.

By entering my name and date below, this constitutes my signature for this online registration.

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* 18. My child may be asked to participate in interviews, photos, and/or videotaping pertaining to this program. I understand that these items may be used for public relations and community awareness activities and are the property of Bibb County School District Before and After School Programs. By entering my first and last names below, I DO NOT want my child to participate in interviews, photos, and/or videotaping pertaining to this program.

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