21st Century Registration Form

2017-18 After-School 21st CCLC Instructional Support/Enrichment Registration
     Bedford Middle School                                                                                                   

                Sept 11, 2017 – Nov. 2, 2017                 3:45-6:00pm

Student Name:  __________________________________________   Grade:   _______

Homeroom Teacher:  __________________ Parent Signature _________________

Contact Phone # ____________________________________________________________________________

Emergency Contact Name:  ________________________________ Emergency Phone #:  __________________

Medical Information (include food allergies): ______________________________________________________

Parent’s e-mail: ______________________________________________________________________________

Yes____ No_____ My child’s photo can be shown in the paper/website

Yes ____No_____ My child may watch the following movies while at the Public library enrichment time.   Cross out any non-acceptable movies: Elana 7, the Secret of Avalor, and Middle school the Worst year, Kung Fu Panda 3, LEGO Batman, Captain Underpants.

**This program is a student commitment to attend each registered class.   Any student who does not come for 3 class times will be dropped from the program  
Parents:   The instructional support/enrichment program is provided free and sponsored by the 21st Century grant.  The program is offered from 3:30-6:00 pm on Monday, through Thursday.  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 support area. 

Class Registration:  Students must enroll in one instructional support time in order to attend the enrichment timePlease list selected instructional classes and enrichment activities below (options shown on back)

Student’s choices:    After School Teacher time                       Enrichment-Public Library   School location    B.U.G
                                                                                                                                                              Class name

Monday:          __________________________________________________________     

Tuesday:          __________________________________________________________     Wednesday:    __________________________________________________________

Thursday:            ____________________________________________________

**Morning instructional time 7:55-8:25.  Students must register to participate. Check days you will come. Morning participation does not include any enrichment participation and is meant for H.W. help or extra help in core subjects.

 ____Monday          ____Tuesday          _____Wednesday          _____Thursday
*Following are the only stops approved for the 21st Century bus.  You must choose from this list:

 (Montvale/Thaxton Bus Route)                          (Big Island Bus Route)

Vista Foods                         Raintree                                           Longwood Minute Mart

Montvale Elementary       State Shop-DOT                                    Liberty High School

Thaxton Market                                                                     Big Island Elementary School                        (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.  Please be on time at drop spots. 

____My child will ride the bus at 6pm and should be dropped off at (circle drop off location listed above)

____My child will be walking home after the instructional support session. (4:50)

____My child will be a car rider and picked up after the instructional support session (4:50)

____My child will be walking home at 6:00 pm.

____My child will be a car rider and be picked up at BMS at 6 pm.

All students are dismissed from BMS, not the enrichment locations unless arranged beforehand.

21st Century Afterschool Programs - Fall 2017 Session -BMS

 After School Teacher time: Mon.-Thurs., (4:00-4:50pm)





Reading Grade 6- Mr. Bryant

Reading 6,7,8Mr. MacDougal

Reading 6,7,8Mr. MacDougal

Reading 6,7,8Mr. MacDougal

Reading 7&8 Mrs. Hoisington

History-grade 6Mr. King

Homework Help – 6,7,8Mr. Booth

Homework Help-6,7,8 Mr. King

Algebra 1 Ms. Bell

Pre-Algebra Ms. Bell

Life Science 6 Ms. Phillips

Hist./Social StudiesMr. Oldaker

Study Skills 6,7,8 Mrs. Meredith

Earth ScienceMs. Phillips

Study Skills 6,7,8 Mrs. Meredith

Geometry (or any math) Ms. Bell

Hist./Social StudiesMr. Oldaker




Morning Instruction

/H.W. help every

Monday- Thursday


Website by SchoolMessenger Presence. © 2017 West Corporation. All rights reserved.