Brookland-Lakeview COLA 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

Grade

Gender

Birth Date

School Attending

For which semester are you registering your student?

PLEASE DIGITALLY SIGN AND UPLOAD YOUR PARENTAL CONSENT FORM BELOW.

Select your child's school form below.

Upload Parental Consent Form

*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 # (optional)

Cell# (optional)

Father's Place of Employment(optional)

Work Telephone # (optional)

Cell # (optional)

Mother's Place of Employment(optional)

Work Telephone # (optional)

Cell # (optional)

Emergency Contact (Other than Parent)

Telephone # (optional)

Cell # (optional)

Emergency Contact #2 (Other than Parent)

Telephone # (optional)

Cell # (optional)

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