New York State 21st Century Community Learning Centers (CCLC) Enrollment Form

Eligible for free lunch *
Language(s) Spoken at Home: *
Ethnicity: Is this student Hispanic or Latino? *
Racial/Ethnic Group: *

Information of Person Enrolling the Student (if different than the student):

Relationship to Student: *
Emergency Contacts Information (fill in order of contact preference):
Authorized to Pick Up *
Release of Student at Dismissal
I give my child permission to walk alone at dismissal: *
My child MAY NOT be picked by the following individuals:
Release of Student During Medical Emergencies

If I am not available during emergencies, my child may be released to one of the following individuals:

Relationship to Student: *
Relationship to Student:
Student’s Health Information

All information is confidential and is used by the program staff to ensure the safety of students.

Does your child have any of the following?

Allergies: *
Does your child need/use an EpiPen? *
Asthma *
Does your child use an inhaler or other medicine for his/her asthma? *
Medical forms must be completed & submitted for your child. See Medical Forms section for downloadable forms.
Diabetes *
Does your child need medication or blood glucose monitoring? *
Does your child have a prescription for glucagon? *
Seizure Disorder *
Does your child need medication for preventing or treating seizures? *
Vision Condition *
Hearing Condition *
Physical Limitations *
Is your child able to participate in physical education class at school with no limitations? *
Other Medication(s) *
Does your child have special diet needs, other health needs, or behavioral/emotional needs? *
I give my child permission to enroll and participate in the 21st CCLC program *
I understand that following agreements and consents ARE NOT PRE-CONDITIONS FOR APPROVAL to participate in the 21st CCLC program *
I consent to emergency medical treatment for my child *
I consent for my child to participate in interviews, the use of quotes, and the taking of photographs, movies, or videotapes by the Program. I also grant Program the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release Program and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. *
I consent for my child to take part in field trips, away from the program site, under supervision. *
I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips. *
I provided information on my child’s special needs to the program to assist in the safety of my child. *
I understand that information regarding my child’s special learning needs will be shared by my child’s school of enrollment with 21st CCLC program staff on a need-to-know basis for my child’s educational benefit *
I agree to review and update this information whenever a change occurs and at least once every year *
I agree to talk to the program staff about my child’s progress and participation in the 21st CCLC program *
If at any time I change my mind about my child’s participation (any or all aspects), I will contact the site coordinator *
Student Data Requirements and Surveys/Interviews Consent

I understand that my child’s academic, behavioral, attendance, and engagement information will be shared with the New York State Education Department and its lawful contractors, to measure and evaluate the quality and implementation of the local 21st Century Community Learning Center (21st CCLC) program as well as the effectiveness New York State’s program in supporting student growth, as required by Title IV, Part B of the Every Student Succeeds Act (ESSA) [see generally sections 4205 (b) and 4203 (14)].

I understand that my child and I may be asked to participate in surveys and/or interviews about the 21st CCLC program and its effects. Only check the following box if you would like to opt-out and not participate in surveys and/or interviews
By signing below, I certify that all information (above) is true and correct to the best of my knowledge. *

Medical Form Section:

Required forms for children with health conditions: