Primary Contact *

First Name

Last Name

Work Phone *

Primary Contact

(###)

###

####

Estimated dates for LOC program *

Let us know the first date you are scheduled to attend LOC.

MM

DD

YYYY

Has this grade attended a LOC program before? *

Yes

No

Mixed - Some have, and others have not.

Are there students attending who qualify for targeted assistance under the Title 1 Program?

Yes

No

Is your school a Title 1 School?

Yes

No

Have you applied for or received other grant funds for this LOC program? *

Yes

No