21st Century Community Learning Centers
2020-2021 ENROLLMENT FORM
(8:15-9:15 AM) (4:00-5:30PM)
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Student Information
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School Name
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Student Name
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Student ID
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Homeroom Teacher
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Grade
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Fort Myers Middle Academy
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Parent Information – (Required)
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Parent Name
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Cell Phone
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Home Phone
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Work Phone
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Email
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My child normally rides the bus to and/or from school: YES or NO (REQUIRED)
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If yes, provide home address:
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Street: _____________________________ City:___________________ Zip:_________
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How will your child get to and home from the sessions? (REQUIRED - check one)
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___ My child will need bus transportation.
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___ I will pick my child up from the tutoring program.
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___ My child will walk/ride bike home from the tutoring program.
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Parent agrees to: (initial beside each activity – SIGNATURE REQUIRED)
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___ Ensure that my child actively participates in the learning process.
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___ Ensure that my child attends the scheduled sessions for the duration of the program.
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___Provide transportation from the school unless other arrangements have been made.
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Parent Signature: ____________________________________ Date:_____________
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The School agrees to: (initial beside each activity)
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___ Enable the student to attain his/her specific achievement goals.
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___ Measure the student’s progress and regularly report progress to parent monthly.
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___ Contact the parent if attendance negatively impacts learning.
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School Representative Signature: ______________________ Date:_____________
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School Use Only
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FSA Math Score:
FSA ELA Score:
2018-2019 Gain:
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