Vine Street 21CCLC Online Registration Child's Name* First Last Going into grade:*List the grade of the student for the 2020-2021 academic year:KindergartenGrade 1Grade 2Grade 3Gender*FemaleMaleEthnicity Child's Date of Birth* MM slash DD slash YYYY Parent/Guardian 1 InformationParent/Guardian 1 Name* First Last Parent/Guardian 1 Address* Street Address City Parent/Guardian 1 Phone*Parent/Guardian 1 Email* Parent/Guardian 2 Information(if applicable)Parent/Guardian 2 Name First Last Parent/Guardian 2 Address Street Address City Parent/Guardian 2 PhoneEmergency Contact(other than Parent/Guardian)Emergency Contact Name* First Last Emergency Contact Relationship to Child* Emergency Contact Phone*Emergency Contact Phone (alternate)Student Contact InformationStudent's Bangor School Dept Email Address (for Google Classroom)* Preferred Email Address for Zoom Invitations* Preferred Phone Number*FeesWe take pride in offering our program to Vine Street families at no cost; however, maintaining a high-quality program is costly, and funding is limited. Any contribution made by participants makes a difference!Contribution* We are able to make a contribution (enter amount below) We are unable to make a contribution at this time Amount of ContributionPlease mail a check payable to "Bangor School Department 21st Century Program" to Vine Street SchoolReleases & PermissionsPlease contact the Director of the 21st CCLC Program with any questions about these releases and permissions.Online LearningRelease to waive Family Education Right to Privacy Act (FERPA) for a Zoom meeting - This form gives permission for your child to participate in Zoom classroom experiences with program staff and other students. By signing below, I state that I understand that other students, students' parents, siblings, or friends who are in the room during the Zoom session may learn protected educational information about my child during these Zoom meetings and I do not hold the Bangor School Department responsible if information about my child is disclosed as a result of a Zoom camp meeting.Photographs and VideosThis form gives permission for your child's photograph and/or video to be used to advocate and/or publicize our 21st CCLC Program. These publications may be used in our school newsletter, brochures, on our website, television, or any other type of publication. By entering my name below, I give permission for my child to participate in any photo or video session that may be part of Vine Street School's 21st CCLC Program.21st CCLC PermissionIn order to provide evidence to maintain our 21st CCLC grant we need to keep track of student demographics, free and reduced lunch status, academic progress and activity participation. All information collected will be restricted and used solely for serving student needs and program evaluation purposes. By entering my name below, I authorize the release of my child's information in order to provide evidence to maintain Vine Street School's 21st CCLC grant and to track overall student progress for program evaluation.Release of LiabilityBy entering my name below, I/we agree to hold harmless and indemnify the Bangor school department, officers, agents, employees, volunteers and contractors from all claims, demands, causes of action that arise from any unintentional or claimed negligent act or omission resulting from any student's participation in the 21st CCLC program.Parent/Guardian Signature* First Last Δ
