2025 21st CCLC Program Registration Form

2025 MCCS 21st CCLC 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.
August 14, 2025- June 1, 2026

Monday to Friday Time: 3 pm - 5 pm
Student Information
First Name*
Last Name*
Student Grade Level:*

K12345
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 1
Full Name*

First NameLast Name
Relationship to student *
Home*
Cell
Work
E-mail*
example@example.com
Address - Same As Child*

YesNo
If your address is different than the student 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
Parent/Guardian Information 2
Full Name

First NameLast Name
Relationship to student *
Home
Cell
Work
E-mail
example@example.com
Address - Same As Childs

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
Other Infomation
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. Write full names. They must bring an valid ID when picking up student and must be of age 18 or older.
Does your child have any siblings in this school?*
If yes, what is their grade level?
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Relationship to student *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home*
Cell
Work
Transportation/Transportation
Form of Transporation/ Forma de transporte?*

Parent pick up/ recogido por el padreSchool Bus / Bus escolarPrivate bus/ bus privado
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 permiso para el autobus.

If you do not qualify for bus, you will receive a call from the school. Si no califica para el bus escolar, usted recibira una llamada de la escuela.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Name of siblings on bus blanks
All registrations are received and reviewed on a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.

Florida Statute § 1002.221 – Student education records are confidential; written parental consent is required before disclosure, except as permitted by law.

Florida Statute § 1002.20 – Parents have the right to access and review all school records related to their minor child.
Signature

Limpiar
Should be Empty:

2025 MCCS 21st CCLC Program Registration Form

August 14, 2025- June 1, 2026

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 permiso para el autobus.