TMMS P.R.I.D.E. 21st CCLC Student Registration

EZ Reports Student Registration

TMMS P.R.I.D.E 21st CCLC Summer Program Monday - Thursday 7:30 am - 12:30 pm
Registration Date

Month Day Year
Date
Student Name *

First Name Last Name
Student Birth Date (REQUIRED)

Month Day Year
Student Gender: *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Student E-mail *
Parent Email
example@example.com
Parent Name *

First Name Last Name
Parent Mobile Number *

Area Code Phone Number
Parent Home Phone

Area Code Phone Number
Parent Work Number

Area Code Phone Number
Insurance Coverage
Medical Condition:
Disabled:

Yes No
Primary Language

English Spanish
Race:

White Black or African American Asian Native Hawaiian or Pacific Islander American Indian or Native Alaskan
Is the student Hispanic or Latino?

Yes No
Is the student Arab/Middle Eastern?

Yes No
School: *

TMMS LJHS RJHS CCJHS SPMA Sparta
Grade (for the 2020 - 2021 school year): *

6th Grade 7th Grade 8th Grade
Transportation Mode: *

Walk Picked Up
Registered By:
Parent/Guardian/21st CCLC Employee
How were you referred?
Why were you referred?

(For Office Use Only) Check all that apply:

Yes

Bilingual

ESL/LEP

Special Education

Title I

SEC 504

Medical

Sect. 31 A

Other "at risk" situation

Not performing at grade level/failing

Student has been truant/suspended

Gifted and Talented

TMMS P.R.I.D.E. 21st CCLC

Student Sign-Out
Student Name *

First Name Last Name
Date

Month Day Year
Date
The following persons have permission to pick up my child/children form the TMMS P.R.I.D.E. 21st CCLC program or to be contacted in the case of an emergency. You must include the individual's name, relationship, & phone number (include yourself). Click the "Add More" button to add each person. Example: Jane Smith, Grandmother, 251-111-1111 *
If applicable, please list any allergies your child may have or any additional important medical information:
Parent Signature *Use the mouse if you are on a computer or use your finger if you are on a cell phone or tablet* *

Clear
Please verify that you are human *
Should be Empty:

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EZ Reports Student Registration