Language
English (US)
Spanish (Latin America)
21st CCLC ACCESS 2020-2021 Application
Virtual After School Program
I understand that the 21st CCLC ACCESS program will be operating remotely until the students are in school full time and my child will need a chromebook to participate.
Yes
No
Student Last Name
*
Student First Name
*
Student ID Number
*
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2012
2011
2010
2009
2008
2007
2006
2005
2004
Year
Grade
*
3
4
5
6
7
8
Gender
*
Male
Female
Primary Language
*
English
Spanish
Other
Race
*
Asian
Black
Hispanic or Latino
Native American
Pacific Islander
White
Other
Education Program (During the day)
*
English Language Learner (ELL)
Special Education
None
Other
School
*
School No. 6
School No. 10
School No. 21
Other
Parent/Guardian Information
Parent/Guardian Last Name 1
*
Parent/Guardian First Name 1
*
Street
*
Phone Number 1
*
Phone Number 2
E-mail Address
Relationship to student
*
Mother
Father
Aunt
Uncle
Grandmother
Grandfather
Guardian
Other
Parent/Guardian Last Name 2
Parent/Guardian First Name 2
Phone Number 1
Phone Number 2
E-mail Address
Relationship to student
Mother
Father
Aunt
Uncle
Grandmother
Grandfather
Guardian
Other
Submit
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