CSCGP Children & Teen Program Membership Form
(one child per form)
Name: *
Age: *
Date of Birth: *
Gender: *
Grade: *
School District: *
Name of Parents/Guardians: *
Address (please include street, city, state, zip code): *
Home phone:
Mobile: Name & Number: *
Mobile: Name & Number: *
Parent/Guardian’s Email: *
Parent/Guardian's Email: *
Child’s Ethnicity:
How did you hear about CSCGP? *
Please describe allergies to food and/or medications. Please note CSCGP often provides snacks. If your child has a special diet, we may not be able to accommodate it. If none, write none. *
Does your child have any special needs or diagnosis? If yes, please explain.
Has your child ever received individual counseling or treatment for psychiatric, behavioral, and/or emotional concerns? If yes, please explain
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