Enrollment sheet

Junction City 21st Century Community Tearning Center

(21CCLC Afterschool Program) Enrollment Form

August 29, 2022 - May 4, 2023

If you are interested in your child participating in the 2021-2022 21CCLC AfterSchool Program

Please fill out the information below and return this form to the school

Bus transportation is available for students living intown only.

If you have any questions call the number below!

elementary office: (870)-899-4043.

***IF YOUR CHILD WILL NOT ATTEND DO NOT SUBMIT THIS FORM.***
Sincerely, Kelsie Crawford Program Director Shelley Ray Site Coordinator
Students name
Grade
Homeroom Teacher
Please Check the days that your student will be attending the program:

MondayTuesdayWednesdayThursday
My student will be riding the bus home. (intown only)
Address
Parent email
example@example.com
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: