Registration Form

General Information
First Name :
Last Name :

Address :
City :
Zip :
County :
Phone No. :
E-Mail :

School Information
School Name :
Grade Level :
Is the student an ESOL * student : Yes
* English as a second language
Gender: Male
Have you registered in any of our programs before? Yes
* If Other, please specify :
Is the student a special needs student? * Yes
* If yes, please specify :

Parent/Guardian Information
Parent(s) :
Phone No. :
Emergency Contact :
Phone No. :

Program Registering
Please specify which programs you're registering : Mentor
After School Program
Tennis Program
Mentee *
* If you checked mentoring, do you have at least 1 parent/guardian or care giver incarcerated? Yes

Bulletin Board

Sun 18th of March 2018

Southern Children Network will
be applying for Georgia 21st
Century Learning Center after
school grant.




1.     After-School Mentors Needed:

One on One mentors needed for

students in the after-scool program.

Training: First Tuesday of each month.

Please call for more information.

May call or email for a one on one


Contact Jinaki if you are attending:
404-697-3672 or

***'Please note that the event time may
change with short notice due to
unforeseen circumstances. Please
confirm date and time.