Brookland Lakeview
21st Century Community Learning Center (21st CCLC)
2023-2024 Brookland-Lakeview 21st Century COLA Program | Afterschool Program
21st Century Community Learning Center
Monday-Friday | 3:30 pm-6:30 pm
Brookland-Lakeview Empowerment Center | Location: 1218 Batchelor Street West Columbia, S.C. 29169
Dr. Benjamin Washington, Project Director | Email address: bewashington@brookland.cc | lakeview@brookland.cc | Office: (803) 744-1967
Student Name
Grade
Gender MaleFemale
Birth Date
School Attending *Northside Middle SchoolEast Point Academy Middle Campus
For which semester are you registering your student? Fall '23 - August 28, 2023 - December 15, 2023Spring '24 - January 29, 2024 - May 17, 2024
NORTHSIDE MIDDLE SCHOOL
EAST POINT ACADEMY MIDDLE CAMPUS
Upload Parental Consent Form
*Transportation from the school and to the home will be provided for Northside Middle School students.
Students will be a (select one) Bus RiderCar Rider
Student resides with Both ParentOne ParentLegal GuardianOther
Name of Parent/Guardian
Address
Home Telephone # (optional)
Cell# (optional)
Email
Father's Place of Employment(optional)
Work Telephone # (optional)
Cell # (optional)
Mother's Place of Employment(optional)
Emergency Contact (Other than Parent)
Telephone # (optional)
Emergency Contact #2 (Other than Parent)
Download Attendance Policies and Procedures Download Revised Behavior Policies & Procedures
I understand that my child must attend regularly, exhibit acceptable behavior, and be picked up promptly at dismissal time if she/he is a car rider.
I acknowledge that all of the information given is correct to the best of my knowledge. I am the parent/guardian and have legal custody of the child being enrolled.
Parent/Guardian Signature
Today's Date