GILCHRIST DISTRICT SCHOOLS
James E. Vickers, Superintendent
21st CCLC Application for Enrollment
Parent: Please complete this application for your child to participate in our new 21st Century Community Learning Center after-school program. Participation is free to parents, but slots are limited. Students will be prioritized based on several factors, so please complete all fields below to the best of your ability. Remember, the program will run from 3:00-6:00 each regularly scheduled school day and will contain components of academic enrichment, family literacy, parent involvement, technology, music, arts, and physical education/obesity awareness. All parents must sign an agreement to participate in family literacy sessions at least four times per year. Return applications to your child’s school by mail, fax, or in person.
Student’s Name: ____________
Parent’s Name: ____________
Current Address: ____________
____________
Current Phone: ______
Current Email: ______
Student’s Grade for 07/08: __ Student’s 06/07 Regular School Day Teacher: _____
Does your child have an Individual Educational Plan (IEP)? Yes / No (please circle)
Language spoken most frequently at home: ______
Highest education level completed by parents: ______
Number of Computers in the Home: ______
What will your child be doing after school if not accepted to this program? __________________
__________________
FOR SCHOOL USE ONLY: FRPL? _ FCAT Reading Level _ FCAT Math Level _
Teacher Recommendation? _ AYP Cell _ Other Info ______
