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
No
* English as a second language
Gender: Male
Female
Have you registered in any of our programs before? Yes
No
Ethnicity
* If Other, please specify :
Is the student a special needs student? * Yes
No
* 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
Tutoring
Administration
Mentee *
* If you checked mentoring, do you have at least 1 parent/guardian or care giver incarcerated? Yes
No

Bulletin Board

Fri 21st of July 2017

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

training.

Contact Jinaki if you are attending:
404-697-3672 or
wilson@southernchildren.org


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