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Name
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First
Last
Preferred Name/Pronouns
Age/Grade
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School
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Non School Email
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Parent/Guardian Information (Note: We need completed information for at LEAST ONE parent/guardian)
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First name Last name
Parent/Guardian Email
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Relationship
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Home Phone
Cell Phone
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Name
First
Last
Relationship
Home Phone
Cell Phone
Medical Information
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Allergies/Conditions/Medications
Primary Doctor
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Phone
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In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above named doctor or in the event the designated preferred practitioner is not available by another licensed physician; and 2) the transfer of the teen to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinion of two other licensed physicians concurring in the necessity for such surgery are obtained prior to the performance of such surgery.
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Parent/Guardian Signature
Photo Release
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Yes
No
I give my permission for EDGE Teen Center to use photos and/or videos that include my student on its social media sites and website, and in publications, printed materials and local media.
Demographics (This information is necessary for the funding of our program. All information will be kept confidential)
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Female
Male
Non-Binary
Other
Prefer not to answer
Gender
Demographics (This information is necessary for the funding of our program. All information will be kept confidential) Select all that apply
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American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Race/Ethnicity (Select all that apply)
Demographics: Student lives with: Select all that apply (This information is necessary for the funding of our program. All information will be kept confidential)
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Mother & Father
Mother(s)
Father(s)
Stepmom
Stepdad
Grandparent(s)
Guardian(s)
Foster Family
Other
Demographics: How may in Household (This information is necessary for the funding of our program. All information will be kept confidential)
Demographics: Household income (This information is necessary for the funding of our program. All information will be kept confidential)
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$0-$15,060
$15,061-$20,440
$20,441-$25,820
$25,821-$31,200
$31,201-$36,580
$36,581-$41,960
$41,961-$47,340
$47,341-$52,720
$52,721+
2024-2025 Community Service STUDENT REGISTRATION FORM COMMUNITY SERVICE PROGRAM PARTICIPATION AND RELEASE AGREEMENT We are excited about having your teenager participate in EDGE’s Community Service Program. By signature below, you acknowledge your awareness of the scope of activities in which your child will participate and recognize that with these activities come some risk and danger. Our adult volunteers and staff will do everything possible to ensure the teen’s safety. However, there is always a risk in transporting youth from one venue to another. There are also some potential risks involved during any off-site volunteer activities. You knowingly take responsibility for your child participating in any of the EDGE Community Service programs and indemnify, release, agree not to sue, and discharge EDGE Teen , Community Service and their agents, for liability and all costs arising from your teenager’s participation in these community service activities. Your teenager has your approval, as parents or legal guardian, to participate fully in all activities, which may include but are not limited to helping to carry and stock food items on shelves, cleaning up both inside and outside facilities, using certain chemicals to help with weeding, riding in the EDGE van or driving to activities themselves. Unless you specifically direct your child not to participate in certain activities and inform the EDGE Community Service Program in writing, we believe your teenager has your approval to volunteer at these sites and participate fully. AGREED TO:
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Participant’s Name
Participant Electronic Signature
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Parent/Guardian Electronic Signature
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Submit
