Brookland-Lakeview COLA Afterschool Program

21st Century Community Learning Center (21st CCLC)

2022-2023 Brookland-Lakeview 21st Century COLA Program | Afterschool Program

21st Century Community Learning Center

Monday-Friday | 3:30 pm-6:30 pm

Brookland-Lakeview Empowerment Center | Location: 1218 Batchelor Street West Columbia, S.C. 29169

Dr. Benjamin Washington, Project Director | Email address: bewashington@brookland.cc | lakeview@brookland.cc | Office: (803) 744-1967

Student Name *

Gender *

School Attending *

Grade *

Birth Date *

PLEASE DIGITALLY SIGN AND UPLOAD YOUR PARENTAL CONSENT FORM BELOW.

Select your child's school form below.

Upload Parental Consent Form *

Choose File

*Transportation from the school and to the home will be provided for Northside Middle School students.

Students will be a (select one): *

Student resides with: *

Name of Parent/Guardian *

Address *

Home Telephone #

Email *

Cell #

Father's Place of Employment

Work Telephone #

Cell #

Mother's Place of Employment

Work Telephone #

Cell #

Emergency Contact (Other than Parent) *

Telephone #

Cell # *

Emergency Contact #2 (Other than Parent) *

Telephone #

Cell # *

Download Attendance Policies and Procedures

Download Revised Behavior Policies & Procedures

I understand that my child must attend regularly, exhibit acceptable behavior, and be picked up promptly at dismissal time if she/he is a car rider.

I acknowledge that all of the information given is correct to the best of my knowledge. I am the parent/guardian and have legal custody of the child being enrolled.

Parent/Guardian Signature *

Today's Date *

Thank you for registering! Your form has been submitted.

There was an error trying to send your message. Please try again later.