2019-2020 Teen Center Registration Form
PLEASE NOTE: There will be a fee of $25 per child. Family fee of $60 for 3 or more children. If you are experiencing hardship with registration fee, please email the Teen Center board members.

REGISTRATION MONEY WILL NOT BE ACCEPTED AT THE DOOR BEFORE AN EVENT. WE MUST RECEIVE PAYMENT AT THE TIME OF REGISTRATION.

Student First Name *
Your answer
Student Last Name *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Entering Grade in September: *
Required
Parent Information
Mother's Name: *
Your answer
Cell Phone# *
Your answer
Email Address: *
Your answer
Father's Name: *
Your answer
Cell Phone #: *
Your answer
Email Address: *
Your answer
Approved Adult Name for Pickup
First and Last Name / Phone Number *
Your answer
First and Last Name / Phone Number *
Your answer
IN CASE OF AN ILLNESS PLEASE LIST NAMES AND TELEPHONE NUMBERS TO CALL IF PARENT CANNOT BE REACHED.
Emergency Contact Full Name / Cell Phone # *
Your answer
Emergency Contact Full Name / Cell Phone # *
Your answer
In the event of a medical emergency and I cannot be reached, I give my permission for my son/daughter to be given immediate medical care at a hospital or other medical/dental facility.
Doctor's Name: *
Your answer
Phone # *
Your answer
Medical Information
Medical Conditions *
Your answer
Medications *
Your answer
Allergies
Food Allergies *
Your answer
Allergies to Medications *
Your answer
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