If you are interested in your child(ren) attending one of our programs, please complete one of the applications below either by printing the application for submisstion or electronically submitting you application.

Chameleon Inapirations Learning Center

PO Box 205

Winnsboro, SC 29180

chameleonilc@yahoo.com

Afterschool Tutoring Program Appplication Link

cilc afterschool application.pdf (51606)

Fairfield County School District Bus Registration Form Link

** Bus registration must be completed in Final Forms

Summer Camp Application Link

cilc summer application.doc (36864)

SC Voucher Childcare Assistance Application Link

Childcare Assistance App.pdf (1177995)

SC Vocuher Childcare Assistance Information

www.scchildcare.org/families/child-care-financial-assistance/

Afterschool Program Application

Date *
Child's First Name *
Child's Last Name *
Date of Birth *
Grade *
School *
Teacher *
Parent(s)/Guardian(s) Names *
Email Adress *
Address *
Work Phone *
Home Phone *
Is your child under medical care or currently taking any medications? *

List persons names and numbers that are authorized to pick up your child *

Child lives with *

Mother
Father
Grandparent
Guardian

Check if any of the following apply
Does Chameleon have your permission to use your child's photo in educational and promotional material? *

Yes
No
Third Choice

I understand my child can be removed from the program for excessive absences, excessive discipline referrals, and unpaid childcare fees *

Yes
No
Third Choice

I give permission to Chameleon Inspirations Learning Center's staff to review my child's academic files (FERPA) for the purposes of assisting with improving my child's academic performance and analyzing program effectiveness *

Yes
No
Third Choice

I agree to hold Chameleon's afterschool program harmless from any and all claims that may result from any actions for damages, such as claim for injuries or accidents, or death during or arising in any way from afterschool/summer program activities *

Yes
No
Third Choice

I authorize Chameleon Inspirations Learning Center to transport my child to a physician for treatment in the event it is not possible to receive instruction from me pertaining to my child's care. I understand I am responsible for any cost incurred *

Yes
No
Third Choice

Child's Physician's Name *
Child's Physician's Address & Phone Number *
Child's Insurance Information *
Please type your name and the date to authorize your signature *

Contact

Chameleon Inspirations Learning Center

P.O. Box 205
542 Fairfield Street, Winnsboro, S.C. 29180

(803) 815-0833 (office)
(803) 402-9367 (mobile)

chameleonilc@yahoo.com

If you are interested in your child(ren) attending one of our programs, please complete one of the applications below either by printing the application for submisstion or electronically submitting you application.

Afterschool Program Application

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