NCCLC Application Form

Student Registration/Permission Form

Which class are you registering your student for?
Student First Name
Student Middle Name
Student Last Name
Street:
City:
State:
Zip:
Mailing Address (if different from above)
Student Phone
Grade Level (2020/21)
Name of Parent/Guardian:
Parent/Guardian Cell Phone:
Name of Parent 2/Guardian 2:
Parent 2/Guardian 2 Cell Phone:
Student lives with:
Home Phone #
Work phone #
Parent E-Mail Address:
Student E-Mail Address:

Name of person to be contacted if parent/guardian cannot be reached:

Name: Phone:
Name: Phone:

I give my student, permission to attend class at(student’s name) The Christian Learning Center for the 2019-20 school term and for my student to correspond with CLC personnel throughout the week. I also give my student permission to be transported, when needed, in transportation provided by the CLC, and for my student to walk with CLC personnel and designated chaperones to locations decided upon by CLC personnel.

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