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Program Registration Form

 

 

BLOOMFIELDMIDDLE SCHOOL
21st CENTURY COMMUNITY LEARNING CENTER
REGISTRATION FORM
2011-2012

 NAME                           ___                    ______            Date of Birth   __  / _      /            GRADE                    ADDRESS                                                    ________               _____                                                  PARENT/GUARDIAN (print)                                     _______         _______                                       PHONE                       ______________            WORK/CELL        _____________                     
E-mail                                                      _________________                                                            

TEACHERS: Math                           _____                       Homeroom___                                                          
GENDER (   ) Male  (   ) Female         LUNCH STATUS (   ) Free   (   ) Reduced    (   ) Full        
PRIMARY LANGUAGE                                                        ETHNICITY                                              

LIVES WITH:    (   ) Both Parents   (   ) Grandparents   (   ) Guardian    (   ) Single Mother        (   ) Single Father     (    )  Foster Care       (   ) Other                                                     
SPECIAL NEEDS (allergies, medications, diet, etc)                   ____________________                                                                 

EMERGENCY CONTACTS/PICK-UP LIST
NAME                                                        PHONE               ____          RELATIONSHIP                                                                                                                           _________                                                                                                                            ________                                                                                                                                                               _______        

PARENTS SIGNATURE                                                                DATE                   

 

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