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Application
CHARLOTTE CSA 21st CENTURY APPLICATION
Sorry! No Longer Accepting Applications for Summer Institute. Call Office at 704.372.3742 for Waiting List.
NAME
Enter Student's Full Name
First Name *
Middle
Last Name *
Gender
Female
Male
Birthdate
Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Student ID #
Grade in Fall 2022
School
Ethnic Identity
Hispanic/Latino
Not Hispanic/Latino
Racial Identity
African American/Black
Asian
Biracial
Native American/Native Alaskan
Native Hawaiian/Other Pacific Islander
White
Program
Select Desired Program
Clara H. Jones Summer Institute
First Baptist-West Music & Tutoring Afterschool
SMART Tutoring Program
Before & After Care
After Care Only
Before & After Care
Before Care Only
Fine Arts - First Choice
Art
Ballet
Brass (3rd-8th Grade)
Violin (3rd-8th Grade)
Piano (3rd-8th Grade)
Fine Arts - Second Choice
Art
Ballet
Brass (3rd-8th)
Piano (3rd-8th)
Violin (3rd-8th)
Parent1/Legal Guardian Information
Prefix
Mr.
Mrs.
Ms.
Prefix
First Name *
Last Name *
Suffix
Parent1/Legal Guardian Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Phone (cell phone preferred)
Cell Phone Provider
Employer & Work Phone
Parent's Email
Child Lives With Parent1/Legal Guardian?
Yes
No
Parent2/Legal Guardian Name
Prefix
Mr.
Mrs.
Ms.
Prefix
First Name
Last Name
Parent2/Legal Guardian Address
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Phone (cell phone preferred)
Cell Phone Provider
Employer & Work Phone
Parent's Email
Child Lives With Parent2/Legal Guardian
Yes
No
Authorized Pick-Up
First Name
Last Name
Address
Country
Address Line 1
City
State/Province
Postal Code
Phone
Authorized Pick Up
First Name
Last Name
Address
Country
Address Line 1
City
State/Province
Postal Code
Phone
Authorized Pick Up
First Name
Last Name
Address
Country
Address Line 1
City
State/Province
Postal Code
Phone
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Student Has Individualized Education Plan - IEP
NO
YES
If Yes, Please Describe.
Chronic Illnesses/Current Medications/Unique Behaviors or Fears
Doctor's Name & Phone Number
Scholarship Application
I understand this program is 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.
Parent/Guardian Electronic Signature
Enter Full Name
Date
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.
Application
Scholarship Verification
Application
Application
Scholarship Verification
News & Events
Newsroom
Event Calendar
Join Our Mailing List
Important Links
Parent Workshops/Advisory Board
Who We Are
Values and Principles
Our History
Frequent Questions
Board
Staff
Financials
What We Do
What We offer
Music and Tutoring Afterschool
Music & Tutoring Afterschool
Application
Parent Workshops/Advisory Board
2022 April Easter Egg Hunt
Spring 2021 End-Of-Year Program
2019 End-Of-Year Luau
2018 Christmas Video & Pics
SMART Tutoring
Clara H. Jones Summer Institute
CLARA H. JONES SUMMER INSTITUTE
APPLICATION
MENU
FINAL PROGRAM VIDEOS & PICS
Career Coaching Program
Grab & Go Lunch
Results
Program Partners
How To Help
Payment/Donation
Volunteer
Get Connected
ENROLL NOW
AFTERSCHOOL
SMART TUTORING
SUMMER INSTITUTE
CAREER COACHING
GRAB & GO LUNCHES
DONATION/PAYMENT