After School Enrollment Form

Nestucca Valley 21st Century Community Learning Centers (NV21CCLC)
2020/2021 School Year

We've got big plans for after school program fun and adventure this year! Even though the program will not take place in person, we will still have fun projects delivered to students through the bus route and we will be operating a homework helpline for students and families to have 1:1 support after the school day instructional hours. The after school program supports academic success, social emotional learning and family engagement.

There are additional spots to add more children at the end of the survey.

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* 1. Student Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

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* 2. Grade

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* 3. Student's Teacher

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* 4. Date of Birth

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* 5. Sex

Male

Female

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* 6. Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 7. Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 8. Parent/Guardian Information

Name

Email Address

Phone Number

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* 9. Language Spoken at Home

English

Spanish

Other

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* 10. Emergency Contact Information

Name *

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number *

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* 11. Additional Student Name & Date of Birth (If needed)

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* 12. Additional Student Name & Date of Birth (If needed)

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* 13. Additional Student Name & Date of Birth (If needed)

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* 14. Additional Student Name & Date of Birth (If needed)

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* 15. Additional Student Name & Date of Birth (If needed)

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* 16. I would like my student to receive help with access to the Homework Helpline 1:1 tutoring only.

Yes

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* 17. I would like my student to receive help from the Homework Helpline AND receive weekly art/activity kids delivered to my home.

Yes

After School Enrollment Form

Nestucca Valley 21st Century Community Learning Centers (NV21CCLC) 2020/2021 School Year

Question Title

* 1. Student Information

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* 2. Grade

Question Title

* 3. Student's Teacher

Question Title

* 4. Date of Birth

Question Title

* 5. Sex

Question Title

* 6. Ethnicity

Question Title

* 7. Ethnicity

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* 8. Parent/Guardian Information

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* 9. Language Spoken at Home

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* 10. Emergency Contact Information

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* 11. Additional Student Name & Date of Birth (If needed)

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* 12. Additional Student Name & Date of Birth (If needed)

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* 13. Additional Student Name & Date of Birth (If needed)

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* 14. Additional Student Name & Date of Birth (If needed)

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* 15. Additional Student Name & Date of Birth (If needed)

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* 16. I would like my student to receive help with access to the Homework Helpline 1:1 tutoring only.

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* 17. I would like my student to receive help from the Homework Helpline AND receive weekly art/activity kids delivered to my home.

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* 18. Please type your name, it represents that you acknowledge your child will be participating in the 20/21 After School Program.

Nestucca Valley 21st Century Community Learning Centers (NV21CCLC)
2020/2021 School Year