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2023-24 21CCLC Student Application

Program Location Attending: *

Dear Families,

As you know 21st Century Community Learning Center (21CCLC) programs were created to provide academic enrichment opportunities during non-school hours for children. Schools qualify for participation in 21CCLC based on their free & reduced lunch rate or Schoolwide Title status.

Through 21CCLC, the South East Education Cooperative (SEEC) receives a federal grant to subsidize the cost of fees for families at qualifying schools. Afterschool programming is operated by SEEC in partnership with your school district.

APPLICATION

Please complete the application below for your student(s) interested in attending the school year program. Note that submission of the application doesn't mean that your student will be accepted as there are a limited number of spots available.

Families will be notified after July 10th if your student(s) has been accepted into the program. If the number of applications exceeds the spots avaialble in the program, we will place your student on a waitlist.

FEES

Program fees are charged on a monthly basis based on free, reduced, and full-pay lunch status. The fee is charged for your child's spot at the program, regardless of your decision to send your child daily. Please provide two weeks notice to withdraw your child from the program. Fees can be paid monthly by check or through automatic withdrawl.

Fees are listed below based on site selection. All fees are per student. If families have multiple students attending the program and are not able to afford the total amount, you may request a scholarship.

Please note that timely payment of fees is crutial for us to be able to continue offering school year and summer programming. Our federal grant does not cover all of the expenses and the program cannot continue without payment of fees. Please note that scholarships are available on the basis of need.

Attendance fees are listed below by site location. All fees are per student. If families have multiple students attending the program and are not able to cover the total amount, you may request a scholarship.

We are looking forward to providing quality out of school time programming for your student.

Parent or Guardian 1 Name: *

Relation: *

Address: *

City, State, Zip *

Phone Number: *

Email address: *

Parent/Guardian 2:

Relation:

Address:

City, State, Zip

Phone Number:

Email address:

Responsibility for payment: *

Parents 1 & 2 (same household)

Parent 1 only (separate households)

Parent 2 only (separate households)

Split between parent 1 & 2 (separate households)

Mapleton Program
August 24th-May 21st. Operates during school days 3:00-6:00PM
Per student monthly fee as marked below: *

Free Priced Lunch $30

Reduced Price Lunch $60

Full Pay $200

Jamestown Programs
Start date August 24th-May 22, operates on school days 3:00-5:15PM.
Montly per student fee as marked below: *

Free Priced Lunch $20

Reduced Price Lunch $50

Full Pay $150

The program in Jamestown is full. You may submit your application to be put on the waitlist. Your student(s) is unable to attend the program until we notify you that a spot is available.

Ellendale Program
Operates September 6 to the end of the school year, 3:25-6PM on days school is in session.
Monthly fee per student as marked below: *

Free Priced Lunch $20

Reduced Price Lunch $50

Full Pay $150

Automatic check withdrawal is an available option. Please indicate whether you would like to receive the forms to sign up to have your checking account automatically debited to pay your monthly fees. *

Yes, please send me information to sign up for on automatic withdrawal

No, do not send me information

Scholarship Request:

I am unable to pay the amounts listed above. Please contact me with information about requesting a scholarship.

Pick Up Permissions/Emergency Contact 1: *

Relationship *

Emergency Contact Phone Number *

Pick Up Permissions/Emergency Contact 2: *

Relationship? *

Phone number: *

Please share any household or custody details that may effect pick-up, billing, and family communication:

Student 1 First Name: *

Student 1 MI: *

Student 1 Last Name: *

Grade 2022-23 School Year: *

Date of Birth *

Gender: *

Ethnicity: *

Classroom Teacher Name: *

Special Education or 504/IEP *

Yes

No

Limited English Proficiency: *

Yes

No

Academic Challenges: *

Yes

No

Check all that apply:

Behavior Plan

Allergies

Medication

Please provide more information about your student's allergies/medication or etc: *

Any additional information about how the program can support your child:

Permission to walk home after dismissal: *

Yes

No

Permission to ride a bus for field trips with the 21CCLC program: *

Yes

No

Primary Doctor: *

Phone: *

Primary Dentist: *

Phone: *

Permission to use the student's name and/or photos in articles, on websites/blog/social media and other materials to promote the 21CCLC program and share accomplishments *

Yes

No

Add another student: *

Yes

No