Please complete this form if you are registering for the 21st CCLC Virtual Summer Academy. Complete one form for each child.

Question Title

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

Question Title

* 2. Select your child's gender.

Question Title

* 3. Select your child's upcoming 2020-21 grade.

Question Title

* 4. Enter your child's date of birth.

Date

Question Title

* 5. Does your child have access to a computer?

Question Title

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

Question Title

* 7. Enter your mailing address.

Question Title

* 8. Enter your contact phone numbers.

Question Title

* 9. Enter your e-mail address.

Question Title

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

Question Title

* 11. I understand that the expectations for good behavior in the 21st CCLC 2020 Virtual Summer Academy are the same as during the regular school day. All regular school day rules apply during the 21st CCLC 2020 Virtual Summer Academy, 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 Virtual Summer Academy.

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

Question Title

* 12. 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. By entering my first and last names below, I certify that I  DO NOT want my child to participate in interviews, photos, and/or videotaping pertaining to this program.

 
100% of survey complete.

T