Ripple Explorers Registration Form 2020

Note: This form is available electronically


                                     21st Century Community Learning Centers

                                            2020-2021 ENROLLMENT FORM

(8:15-9:15 AM)  (4:00-5:30PM)

Student Information

School Name

Student Name

Student ID

Homeroom Teacher


Fort Myers Middle Academy





Parent Information – (Required)

Parent Name

Cell Phone

Home Phone

Work Phone








My child normally rides the bus to and/or from school: YES or NO (REQUIRED)

If yes, provide home address:


Street: _____________________________ City:___________________ Zip:_________


How will your child get to and home from the sessions? (REQUIRED - check one)

___ My child will need bus transportation.

___ I will pick my child up from the tutoring program.

___ My child will walk/ride bike home from the tutoring program.


Parent agrees to: (initial beside each activity – SIGNATURE REQUIRED)

___ Ensure that my child actively participates in the learning process.

___ Ensure that my child attends the scheduled sessions for the duration of the program.

___Provide transportation from the school unless other arrangements have been made.


Parent Signature: ____________________________________ Date:_____________


The School agrees to: (initial beside each activity)

___ Enable the student to attain his/her specific achievement goals.

___ Measure the student’s progress and regularly report progress to parent monthly.

___ Contact the parent if attendance negatively impacts learning.

School Representative Signature: ______________________ Date:_____________

School Use Only

FSA Math Score:
FSA ELA Score:
2018-2019 Gain:



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