Registration Form - Danville Church & Community Tutorial Program

Dear Parents/Guardians,

Churches throughout Danville, Pittsylvania and Caswell County are sponsoring a tutorial program. This program will provide students with homework assistance, mentoring to build self-esteem, math and reading remediation and enrichment, field trips, and STEM (science, technology, engineering, math) activities.

Student’s Legal Name

First Middle Last

Grade

Present School Student is Attending

Did your child every attend preschool or Head Start?

Student’s Email Address:

Student’s Cell Phone:

Gender

Male
Female

Race

Black
White
Hispanic/Other

Date of Birth

Student lives with:

Parent’s/Guardian’s Email Address:

Parent’s/Guardian’s Marital Status:

Mother

First Name Last Name

Mother's Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mother's Employer

Mother's Work Number

Father

First Name Last Name

Father's Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father's Employer

Father's Work Number

In case of an emergency, please call:

First Name Last Name

Relationship to child

Emergency Contact's Home Phone Number

Emergency Contact's Work Phone Number

(Secondary contact) In case of an emergency, please call:

First Name Last Name

(Secondary contact) Relationship to child

(Secondary contact) Emergency Contact's Home Phone Number

(Secondary contact) Emergency Contact's Work Phone Number

Any allergies or health impairments?

Yes
No

List any allergies, health issues and or disabilities:

Check the appropriate boxes.*

Yes, I want my child to attend the Danville Church & Community Tutorial Program and I voluntarily release my child’s academic grades from the school system to the Danville Church & Community Tutorial Program (DCCTP) to enhance the scholastic development of my child.
I understand that this is not a requirement for my child to participate in the program.
I give my permission to take pictures for advertisement of the DCCTP activities (ex. newspaper, websites, social media, etc.)

Parent/Guardian Name

First Name Last Name

Parent/Guardian Signature*