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Club Connections

Club Connections Registration

2024-2025 Club Connections Registration


Would you like to be contacted in addition to your parents?
If yes, please provide your email and phone number below
DO YOU GIVE PERMISSION FOR CLUB 21 TO SHARE YOUR NAME, EMAIL, AND PHONE NUMBER WITH THE PROGRAM ROOM PARENT?
Room parents will be coordinating opportunities for connection outside of class meetings.
Special Diet:
If "other" please indicate what that is:

Answering the questions below,  will help our Club Connections Team create lessons that can meet a diverse group of needs.

Any difficulty with sight or hearing?
If yes, please indicate what those are:
Does Club 21 have permission to release photos of your teen:
by clicking "yes" you give your consent
Club Connections Payment Options
If you are requesting funding from your Regional Center, please check this box:

If you are using Self Determination funds, please fill out this information:

According to your spending plan
Payment Option
Credit Card Information
Make this a monthly payment?
Make this a monthly payment?
Your total payment will be
Your credit balance will cover
Your credit card will be charged
Your bank account will be charged
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