CLC Form for ComEd Music Lessons
This form gives permission for your child to leave Community Learning Centers during program hours to participate in another approved activity.
Student Name
*
First Name
Last Name
Please select lesson type
*
Piano
Guitar
Instructor's Name
*
Please Select
Ainsley Meyers
Allan Saugstad
Amy Hartzler
Charity Wessel
Jame Hernane
Jasmine (Simin) Zhao
Linda Lang
Lynn Thomason
Paula Pelayo
School Location:
*
Please Select
Discovery
Eugene Field
JFK
John Harris
Laura B. Anderson
Susan B. Anthony
Terry Redlin
Which day of the week will lessons take place:
*
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Lesson Start Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Lesson End Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Lesson Start Time:
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Will your child be returning to CLC at the end of their lesson?
*
Yes
No
Acknowledgements
Please acknowledge the following statements.
I acknowledge that my child (name listed above) will be signed out of the Community Learning Centers program during this the program time listed above. My child will no longer be under the care of CLC/BGCSE/VOA/YMCA and transferred to the care of the Instructor (name listed above) at the time the program begins.
*
Yes
Parent/Guardian Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: