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GCC Summer 2022 Application
*
1.
First Name
(Required.)
*
2.
Last Name
(Required.)
*
3.
Gender
(Required.)
Female
Male
*
4.
Ethnicity
(Required.)
American Indian/Alaskan
Native
Asian
Native Hawaiian or Pacific Islander
Black/African American
Hispanic/Latino
White
*
5.
Special Education and/or 504
(Required.)
Yes
No
*
6.
Limited English Proficiency
(Required.)
Yes
No
*
7.
Free/Reduced Lunch
(Required.)
Yes
No
*
8.
Grade 21-22
(Required.)
9.
Classroom Teacher
*
10.
Birthdate
(Required.)
Parent / Guardian 1
*
11.
Relation
(Required.)
Mother/Stepmother
Father/Stepfather
Grandparent
Foster Parent
Other
*
12.
Contact Information
(Required.)
Name
Address
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
Parent / Guardian 2
13.
Relation
Mother/Stepmother
Father/Stepfather
Grandparent
Foster Parent
Other
14.
Address
Name
Address
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
*
15.
Permission to walk home alone after dismissal
(Required.)
Yes
No
*
16.
Ride bus when available
(Required.)
Yes
No
*
17.
Pick Up Permissions/Emergency Contacts 1
(Required.)
Name
*
Relation
Phone Number
*
18.
Pick Up Permissions/Emergency Contacts 2
Name
Relation
Phone Number
19.
Child may NOT be picked up by
Medical Information
*
20.
Primary Doctor
(Required.)
*
21.
Phone
(Required.)
*
22.
Dentist
(Required.)
*
23.
Phone
(Required.)
*
24.
Special Alerts/Restrictions
(Required.)
*
25.
Permission to use student’s name and/or photos in articles, on websites/blog/social media, and other materials to promote the program and share accomplishments:
(Required.)
Yes
No
*
26.
I understand that JSVC 21CCLC Program is part of our local public school. Program staff will have access to school records needed for my child’s participation.
(Required.)
I understand
27.
Add another student
Yes
No
Current Progress,
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