LRSD 21st Century Community Learning Centers

LITTLE ROCK SCHOOL DISTRICT21st Century Community Learning Centers 2021-22 Student Application Washington
21st CCLC Afterschool Program en Español

Please fill out this form for each child applying to the afterschool program.

After school students will participate in academic tutoring and homework assistance as well as fun enrichment activities including: art, dance, musical instruments, computers, building robots, STEM, photography, health and wellness and much more. There is a limit to the number of students that can participate - WE MAY NOT BE ABLE TO ACCEPT EVERY STUDENT WHO APPLIES. If your child is selected, an acceptance letter and program information will be sent to you. If your child is not selected his/her name will be placed on a waiting list.

Afterschool program will begin Tuesday, September 15, 2020. The calendar and additional information will be sent out as soon as it is approved.

We are currently determining whether to hold a blended (on-site and virtual students) or 100% virtual program for the Fall semester.

Directions:

Complete all of the information below.
A parent/guardian must attest to the contents of this form.

Clear Form and Complete Application for Another Student

Student Details

Student First Name

Student Last Name

Student Id

DOB

Teacher Name

Grade 2nd 3rd 4th 5th

Delivery of Instruction In-Person Virtual

What is the student’s primary mode of transportation?
Bus CARE (at the school) Day Care (off site) Walker Car

Does your child need transportation home from After School?
Yes No

Address

City

ZipCode

Parent/Guardian Details

Parent First Name

Parent Last Name

Phone

Sibling List

Program Goals

To improve reading, writing and math skills on school and state assessments
To enhance learning, critical thinking, problem solving and to build character and social skills
To provide a safe, healthy and nurturing environment
To have fun

I reviewed and understand the program goals: Yes No

Attendance and Behavior

All students are expected to attend each session (M-Thur.). Five consecutive absences will constitute dismissal from the program. Ms. Wilkins, the Site Coordinator, will notify the parents after the second absence. If a student has 3 unexcused absences within a month the student may be dropped from the program. Students whose behavior adversely affects the learning environment in any way, will be dismissed from the program.
I read and understand the attendance and behavior policy: Yes No

Acknowledgement

By signing this form, I am acknowledging that my child will attend and I will support my child's involvement in the BTW 21st Century Program. I will make sure my child attends all sessions. exhibits good behavior and a good attitude for learning. I understand if my child's behavior adversely affects the group in any way that he/she may be dismissed from the group. Yes No

Parent/Guardian Verification

Type Your Full Name

6/12/2026

Current Date

By selecting this checkbox, you attest you are the Parent/Guardian of the student listed above.

Submit