Course Selection Form

Course Selection Form

LCCA After School Program
Student Name

First NameLast Name
Grade Level
Class Selection

Art - Grades 6 - 8 -Thursday 4:00pm - 5:00pm - Mrs . CombsMusic - Trumpet - Friday 3:00pm - 3:45pm - Mr. LevyMusic - French Horn - Friday 4:00pm - 4:45pm - Mr. LevyReaders Theater - Tuesday 5:00pm - 6:00pm - Ms. Windham
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian hone Number
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Student Signature (if able)

Clear
Date Signed

MonthDayYear
Date
Parent Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty: