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Application

CHARLOTTE COMMUNITY SERVICES ASSOCIATION SORRY! NO LONGER ACCEPTING SUMMER APPLICATIONS

Program
Select Desired Program
BEFORE/AFTER SCHOOL
Enter Student's Full Name
First Name *
Middle
Last Name *
Gender
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Ethnic Identity
Racial Identity

Following Questions Apply Only To Summer Institute Students--For Pre-K, Skip to Parent/Guardian Info

Student Has Individualized Education Plan - IEP
If Yes, Please Describe.
Fine Arts - First Choice
Fine Arts - Second Choice
Prefix
First Name *
Last Name *
Suffix
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Child Lives With Parent1/Legal Guardian?
Prefix
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Child Lives With Parent2/Legal Guardian
First Name
Last Name
Country
Address Line 1
City
State/Province
Postal Code
First Name
Last Name
Country
Address Line 1
City
State/Province
Postal Code
First Name
Last Name
Country
Address Line 1
City
State/Province
Postal Code
Scholarship Application
If scholarship is requested, parent/guardian must submit proof of income to info@charlottecsa.org. This includes cover sheet of most recent income tax form (with Social Security numbers blacked out). I understand my child is required to maintain an 80% attendance rate and I give permission for general income and student data information to be shared with appropriate funders.
Tuition is $1,000 for the entire program--or $166.66 per week. This price includes before and after care, food, field trips, instruments and t-shirts. Due to below-market rates, we do not pro-rate for vacations, two-week periods or sibling discounts. Payments can be made anytime between now and June 24 on this website at "DONATION/PAYMENT."
Orientation Required
Image Authorization
I give permission for my child's photo or likeness to be used in media related to the program.
Emergency Medical Authorization
I agree that the agency may authorize a medical practitioner of its choice to provide emergency care if a timely response is needed or if I can not be contacted.
Enter Full Name

NOTE: PARENTS OF AFTERSCHOOL STUDENTS MUST CONTACT THE SCHOOL OR CMS TRANSPORTATION TO ARRANGE BUS PICKUP OR DROPOFF

The Family Educational Rights and Privacy Act is a Federal law protecting student education records privacy. Parents have the right to inspect their child's records and request errors be corrected.

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