Language
English (US)
Spanish (Latin America)
21st CCLC ACCESS 2019-2020 Application
Student Last Name
*
Student First Name
*
Student ID Number
*
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2011
2010
2009
2008
2007
2006
2005
2004
2003
Year
Grade
*
3
4
5
6
7
8
Gender
*
Male
Female
Primary Language
*
English
Spanish
Other
Race
*
Asian
Black
Hispanic or Latino
Native American
Pacific Islander
White
Other
Education Program (During the day)
*
English Language Learner (ELL)
Special Education
None
Other
School
*
Martin Luther King Jr. School No. 6
Theodore Roosevelt School No. 10
Sonia Sotomayor School No. 21
I give permission for the nurse to share allergy information with the 21st CCLC ACCESS after school program
*
Yes
No
At 6:00 the student will...
*
Walk home
Be picked up
Parent/Guardian Information
Parent/Guardian Last Name 1
*
Parent/Guardian First Name 1
*
Street
*
Phone Number 1
*
Phone Number 2
E-mail Address
Relationship to student
*
Mother
Father
Aunt
Uncle
Grandmother
Grandfather
Guardian
Other
Authorized to pick up student
*
Yes
No
Parent/Guardian Last Name 2
Parent/Guardian First Name 2
Phone Number 1
Phone Number 2
E-mail Address
Relationship to student
Mother
Father
Aunt
Uncle
Grandmother
Grandfather
Guardian
Other
Authorized to pick up student
Yes
No
Emergency Contact other than parent/guardian
Emergency Contact Last Name 1
*
Emergency Contact First Name 1
*
Emergency Contact Address (include city)
*
Emergency Contact Phone Number 1
*
Emergency Contact Phone Number 2
Relationship to student
*
Aunt
Uncle
Grandmother
Grandfather
Guardian
Family Friend
Cousin
Other
Authorized to pick up student
*
Yes
No
Emergency Contact Last Name 2
Emergency Contact First Name 2
Emergency Contact Address (include city)
Emergency Contact Phone Number 1
Emergency Contact Phone Number 2
Relationship to student
Aunt
Uncle
Grandmother
Grandfather
Guardian
Family Friend
Cousin
Other
Authorized to pick up student
Yes
No
Submit
Should be Empty: