Average Daily Building: Grade Levels: Enrollment: Subgroups: Average District: Attendance: Average Daily Building: Grade Levels: Enrollment: Subgroups: Average District: Attendance: *Must have live signature If space is needed to list more than 5 participating centers/ school, use additional copies of this page Center Information SUMMER – School Building(s) Targeted Student School Building Center Name Number of Students and District Population - Principal services Served by of Target Grade Levels Printed Name and are provided) Center Site Student Population and Subgroups Signature* Enrollment: Building: Grade Levels: Subgroups: Average Daily District: Attendance: Enrollment: Building: Levels: Subgroups: Average Daily District: Attendance: Average Daily Building: Levels: Enrollment: Subgroups: Average Daily District: Attendance: Average Daily Building: Grade Levels: Enrollment: Subgroups: Average Daily District: Attendance: Average Daily Building: Levels: Enrollment: Subgroups: Average Daily District: Attendance: *Must have live signature If space is needed to list more than 5 participating centers/ school, use additional copies of this page Services to be provided: (check all that apply) Adult Family Member Involvement and Literacy Attendance Recovery Community Service
Average Daily Enrollment: Building: Grade Levels: Subgroups: Average Attendance: District: Average Daily Enrollment: Building: Grade Levels: Subgroups: Average Attendance: District: *Must have live signature If space is needed to list more than 5 participating centers/ school, use additional copies of this page Center Information – SUMMER Center Name services are provided) Number of Students Served by Center Site School Building(s) and District of Target Student Population Targeted Student Population - Grade Levels and Subgroups School Building Principal Printed Name and Signature* Enrollment: Building: Grade Levels: Subgroups: Average Daily Attendance: District: Enrollment: Building: Levels: Subgroups: Average Daily Attendance: District: Average Daily Enrollment: Building: Levels: Subgroups: Average Daily Attendance: District: Average Daily Enrollment: Building: Grade Levels: Subgroups: Average Daily Attendance: District: Average Daily Enrollment: Building: Levels: Subgroups: Average Daily Attendance: District: *Must have live signature If space is needed to list more than 5 participating centers/ school, use additional copies of this page Services to be provided: (check all that apply) Adult Family Member Involvement and Literacy Attendance Recovery Community Service
DOE_19005_21stClcc_appB_rev.docx