GCC Summer 2022 Application

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* 1. First Name

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* 2. Last Name

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* 3. Gender

Female

Male

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* 4. Ethnicity

American Indian/Alaskan

Native

Asian

Native Hawaiian or Pacific Islander

Black/African American

Hispanic/Latino

White

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* 5. Special Education and/or 504

Yes

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* 6. Limited English Proficiency

Yes

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* 7. Free/Reduced Lunch

Yes

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* 8. Grade 21-22

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* 9. Classroom Teacher

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* 10. Birthdate

Parent / Guardian 1

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* 11. Relation

Mother/Stepmother

Father/Stepfather

Grandparent

Foster Parent

Other

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* 12. Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Parent / Guardian 2

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* 13. Relation

Mother/Stepmother

Father/Stepfather

Grandparent

Foster Parent

Other

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* 14. Address

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 15. Permission to walk home alone after dismissal

Yes

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* 16. Ride bus when available

Yes

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* 17. Pick Up Permissions/Emergency Contacts 1

Name *

Relation

Phone Number *

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* 18. Pick Up Permissions/Emergency Contacts 2

Name

Relation

Phone Number

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* 19. Child may NOT be picked up by

Medical Information

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* 20. Primary Doctor

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* 21. Phone

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* 22. Dentist

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* 23. Phone

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* 24. Special Alerts/Restrictions

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* 25. Permission to use student’s name and/or photos in articles, on websites/blog/social media, and other materials to promote the program and share accomplishments:

Yes

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* 26. I understand that JSVC 21CCLC Program is part of our local public school. Program staff will have access to school records needed for my child’s participation.

I understand

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* 27. Add another student

Yes