2016-17 After-School 21st
CCLC Instructional Support/Enrichment Registration Bedford Middle School April 17-21, 2017 3:45-5:30pm
Student Name: __________________________________________ Grade: _____
______________ Parent Signature ______________________
Contact Phone # __________________________________________________
Emergency _Contact Name:
________________________________ Emergency Phone #: __________________
Medical Information (include food allergies): ______________________________________________________
Parent’s e-mail: ______________________________________________________________________________
This program is a
student commitment to attend each registered class.
Parents: The instructional support/enrichment program
is provided free and sponsored by the 21st Century grant. The program is offered from 3:45-5:30pm,
Monday through Friday. Participating
students will stay at school after normal afternoon dismissal, reporting to the
cafeteria at 3:45. A snack will be given
to each after school participant, at 4:00 they will report to their designated afternoon
is extra help/review for the upcoming SOL’s beginning April 24.
Student’s choices: After School SOL prep time – circle ALL
your choices, mark your grade level/class name (ex. Algebra 1, concepts, Civics,
etc) Grade Math/History/Science class
Monday: READING or SCIENCE_______________________________
Tuesday: READING or SCIENCE_______________________________
Wednesday: MATH or
Thursday: MATH or
Friday: SCIENCE or
*Following are the only stops approved for the 21st
Century bus. You must choose from this
(Montvale/Thaxton Bus Route) (Big Island Bus Route)
Vista Foods Raintree Longwood
Montvale Elementary State Shop-DOT Liberty High School
Thaxton Market Big Island Elementary
(Exceptions are possible
if student lives directly on routes-check with Mrs. Slingerland)
The following information is needed from all students.
Please note that the 21st Century bus will not wait for
parents/guardians at the stops and may take your child back to school if no one
is there to get them.
____My child will ride the bus at 5:30pm and should be
dropped off at (circle drop off location listed above)
____My child will be walking home after the instructional
support session. (5:30pm)
____My child will be a car rider and picked up after the
instructional support session (5:30pm)
All students are dismissed from BMS at 5:30pm
Registration forms are due as soon as possible or by Thursday, April 6. Forms can be sent
back with students, emailed or Faxed, 586-4957.
If you have questions or concerns, please contact Mrs.
Slingerland at BMS (586-7735) or