21C Extended Day Registration (After-School Care)

Parent / Guardian Name

First Name

Last Name

Parent / Guardian Email

Home or Mobile Phone

(###)

###

####

Student Name

First Name

Last Name

Student's Home School

Student's Birth Date (mm/dd/yy)

Student's Racial / Ethnic Group

Student's Gender

Address Where Student Will Reside for 2023-2024 School Year for Pick-Up and Drop-Off

Special Service or Program (if applicable)

Grade for 2023-2024 School Year

Permission

I give permission to have my child's Personal Identifiable Information (PII) and any other performance-related information released to the Louisiana Department of Education and Youth Services, contractor of the web-based database system for the 21st Century Community Learning Center (21st CCLC) after-school/extended-day programs for purposes of evaluating performance and measuring the child's progress. I give my child permission to go on walking field trips with the ReNEW 21C ED Program.

Yes

Sibling 1 - Name & Grade

Example: John Smith / 4th Grade

Sibling 1 - Date of Birth

mm/dd/yyyy

Sibling 2 - Name & Grade

Sibling 2 - Date of Birth

Sibling 3 - Name & Grade

Sibling 3 - Date of Birth

Choose Activities

4th-8th Grade Only

Band

Auxilary (Dance, Majorettes, Flag, Cheer, Drill)

Tutoring and Homework Help

Sports

Transportation

Emergency Contact Information

Emergency Contact #1 - Name

First Name

Last Name

Relationship to Student

Emergency Contact #1 - Phone

(###)

###

####

Emergency Contact #2 - Name

First Name

Last Name

Relationship to Student

Emergency Contact #2 - Phone

(###)

###

####

Child May Be Picked Up By

Person who is authorized to pick up student

First Name

Last Name

Relation to Student

Phone

(###)

###

####

Child May *NOT* Be Picked Up By

(If this is due to parental custody agreement, please provide the legal documentation for your child's file)

First Name

Last Name

Relation to Student

List Any Allergies for Your Student

List Any Medications Your Student Takes

Also add any pertinent notes

**IMPORTANT NOTE**