2024- 2025 21st CCLC Afterschool Program Registration Form

All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.

First Name*

Last Name*

Student Grade Level:*

Gender*

FemaleMale

Birth Date*

MonthDayYear

Home Phone*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent or Guardian Address - Same As Child*

YesNo

Full Name*

First NameLast Name

Home*

Cell

Work

E-mail*

example@example.com

If your address is different than the childs please fill out the info below. Otherwise move onto the next section.

Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Full Name

First NameLast Name

Home

Cell

Work

E-mail

example@example.com

Address - Same As Child

YesNo

If your address is different than the childs please fill out the info below. Otherwise move onto the next section.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Does your child have any allergies?*

YesNo

If yes please list, including any food or drug allergies.

Does your child have any medical conditions?

Please list the people authorized to pick up your child. All authorized adults must be of age 18 or older and show a valid ID, every single time they pick up the student.

Does your child have any siblings in this school?*

If yes, what is their name and grade level?

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home*

Cell

Work

IN THE EVENT NO ONE CAN BE CONTACTED, I GIVE PERMISSION FOR MY SON/DAUGHTER TO RECEIVE EMERGENCY MEDICAL TREATMENT:

YesNo

IF NO WAS CHECKED IN THE PREVIOUS BOX, PLEASE PROVIDE A PROTOCOL TO FOLLOW:

Form of Transporation/ Forma de transporte?*

Parent pick up/ recogido por el padreSchool Bus / Bus escolarPrivate bus/ bus privado

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

PLEASE LIST ALL SIBLINGS RIDING THE BUS

All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.

Please read the following: In consideration of accepting this application for registration in the Miami Community Charter Schools 21st CCLC afterschool program (the “Program”), I, the parent or legal guardian of the participant described above, intending to be legally bound, for the participant and his/her heirs, guardian and personal representatives, do herby, waive and release Miami Community Charter Schools, 21st CCLC, and Miami-Dade County Public School System and all other municipalities, schools, clubs, and private agencies, their officers, directors, agents, employees, volunteers and assigns from any sponsors for any and all injuries suffered by my child/ward as a result of his/her participation in the Program. I represent that I have the authority to acknowledge and sign this registration for the purpose set forth herein and that no other consents are required. I hereby grant full permission to any and all of the foregoing parties to use the participant's photograph, likeness and voice, including but not limited to, videotapes, recordings, television broadcasts or any other record of these events to any purpose related to the Program, without payment of any additional consideration. It is further agreed that the participants will be evaluated using this Program and that these evaluations may be used and the results made public. These evaluations will be based on data which will include but may not be limited to, the participants’ grades, attendance records and test scores as recorded with the Miami-Dade County Public Schools and other agencies. The participants’ names will not be used in connection with any public use of these evaluations without the expressed written consent of the participant and their parent, guardian or legal custodian. I certify that all of the information contain herein is true and correct.

2024-2025 MCCS 21st CCLC Afterschool Program Registration Form

August 15, 2024- May 21, 2025

4 Saturday and Spring Session

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian

Transportation/Transportation

If you have selected school bus for transportation please fill in the following information. All bus applicants must fill out a Bus Permission Form. Si eligió el autobús escolar, complete la siguiente información. Todos los applicantes deben llenar la forma de permission para el autobus.