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Application

CHARLOTTE COMMUNITY SERVICES ASSOCIATION STUDENT APPLICATION

Program
Select Desired Program
Before & After Care
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 Afterschool 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
I understand this program may be free but my child is required to maintain an 80% attendance rate. I also give permission for my family's income information and child's information to be shared with appropriate funders.
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

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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