Irving Elementary/Belle Elementary

"21st Century Community Learning Center Schools" Summer 2022 Registration Form

Summer School Date: May 26, 2022 - June 23, 2022

My Child will attend Summer School

My Child will attend Summer School Yes No
Student Name: Student Name: First Last
Gender:

Gender: Male Female
Date of Birth: Date of Birth: / MM / DD YYYY
Present Teacher's Name:
Present Grade Level:
Home Address: Home Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent's/Guardian's Name: Parent's/Guardian's Name: First Last
Primary Phone: Primary Phone: - ### - ### ####
Emergency Contact: Emergency Contact: First Last
Emergency Contact Phone Number: Emergency Contact Phone Number: - ### - ### ####
Do you want paper packets or will your child be attending class online?

Do you want paper packets or will your child be attending class online? Paper packet Online
Address for packet drop-off (if packet has been requested) Address for packet drop-off (if packet has been requested)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Do we have your permission to use photos for publication purposes?

Do we have your permission to use photos for publication purposes? Yes No
Do we have your permission to gather data through surveys and interviews?

Do we have your permission to gather data through surveys and interviews? Yes No
Do we have permission to acquire academic records from the school?

Do we have permission to acquire academic records from the school? Yes No
Do we have permission to transport your child for field trips or other program needs?

Do we have permission to transport your child for field trips or other program needs? Yes No
Please let us know if your child has any physical limitations, chronic illness, and/or food allergies.
I hereby grant permission for my child to participate in the Irving Elementary/Belle Elementary/21st CCLC Summer school program.

Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature.

Irving/Belle Elementary summer school programs are part of a 21st Century Community Learning Center brought to you by a partnership between Kewanee Schools and Regional Office of Education. Clear

Full Name

I understand this is a legal representation of my signature.

Irving/Belle Elementary summer school programs are part of a 21st Century Community Learning Center brought to you by a partnership between Kewanee Schools and Regional Office of Education.