COLA Afterschool Program Registration - Brookland Lakeview Empowerment Center

2021-2022 BROOKLAND-LAKEVIEW COLA AFTERSCHOOL PROGRAM

21st Century Community Learning Center | Northside Middle School

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

Dr. Burnett Joiner, Project Director | Email address: burnettjoiner@gmail.com| Mobile: (803) 351-5364 | Office: (803) 744-7943

Student Name *

Gender *

Grade *

Birth Date *

The Afterschool Program meets Mondays, Fridays and Saturdays. Students have the option to attend the full program everyday or dismiss early. Please check your choice below:

Students will be a (select one): *

Student resides with: *

Name of Parent/Guardian *

Address *

Home Telephone #

Cell #

Father's Place of Employment

Work Telephone #

Cell #

Mother's Place of Employment

Work Telephone #

Cell #

Emergency Contact (Other than Parent) *

Telephone #

Cell # *

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 *

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Brookland-Lakeview COLA Afterschool Program