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EDGE@East Registration 2024-25
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Student Information
Name
*
First
Last
Date of Birth
*
MM
1
2
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9
10
11
12
DD
1
2
3
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5
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9
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13
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17
18
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20
21
22
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24
25
26
27
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30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1994
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1991
1990
1989
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1986
1985
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1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender (optional)
Grade
*
9th
10th
11th
12th
School
*
Pronouns
Home Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
Mobile Phone
Student Email
Parent/Guardian Information
(NOTE: We must have complete information for at least one parent/guardian.)
Name (1)
*
First
Last
Relationship (1)
*
Email (1)
*
Mobile Phone (1)
*
Work Phone (1)
Place of Employment (1)
Name (2)
First
Last
Relationship (2)
Email (2)
Mobile Phone (2)
Work Phone (2)
Place of Employment (2)
Other Emergency Contact
Name
*
First
Last
Phone
*
Medical Information
Medications/Conditions
Allergies
Primary Doctor
*
Doctor's Phone
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.
Signature
*
By typing my name above, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Today's Date
*
Demographics
(This section must be completed. It is necessary for the funding our organization receives. All information is kept confidential.)
Ethnicity
*
Black
White
Hispanic
Latino
Asian
Native American
Multi-Racial
Other
Other (Ethnicity)
Household Income
*
$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+
Student Lives With (check all that apply)
*
Mother & Father
Mother(s)
Father(s)
Step Mom
Step Dad
Grandparent(s)
Guardian(s)
Foster Family
Other
Other (Student Lives With)
Number of Individuals in Household
*
Student qualifies for free/reduced lunch
*
Yes
No
Language spoken at home
*
Photo Release
*
Yes
No
I give my permission for EDGE Teen Centers 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.
Academics
*
Yes
No
I give permission for my student to access his/her/their Home Access Center (HAC) and CANVAS account while in the presence of EDGE Teen Centers staff/adult volunteers. I also give EDGE Teen Centers and my child’s school district permission to exchange information regarding the minor child listed on this registration form. The purpose of this exchange is to help both organizations more effectively support the student’s academic goals.
Physical Education and Activity
*
Yes
No
I give permission for my student to participate in physical education and physical activities provided by EDGE Teen Center. Specifically, I understand that EDGE Teen Center may contract with outside instructors to lead these activities for the benefit of my student. By signing, I waive any cause of action against EDGE Teen Center and the instructor of any activity sanctioned by EDGE Teen Center for any injury, loss, or damages to person or property. Participation in physical education and physical activities involves inherent risks of physical injury, pain, and suffering.
Prevention-based Activity
*
Yes
No
I give permission for my student to participate in the prevention-based organized activities provided by EDGE Teen Center. Specifically, I understand that EDGE Teen Center may contract with outside instructors to lead these activities for the benefit of my student. By signing, I waive any cause of action against EDGE Teen Center and the instructor of any activity sanctioned by EDGE Teen Center for any injury, loss, or damages to person or property.
Behavioral Health
I have completed the “consent for treatment” counseling form.
A licensed counselor from Focus On Youth is at EDGE@West weekly to lead small groups. They will also offer free individual counseling for teens who may need support dealing with life stressors, but a signed consent form must be on file for a teen to use this service.
SIGNATURES NEEDED
Student Signature
*
By typing my name above, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature, and I (student) acknowledge that I have reviewed the EDGE Teen Center Code of Conduct and agree to abide by it. This document can be found at the top of the Enroll page.
Today's Date
*
Parent Signature
*
By typing my name above, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
Today's Date
*
Submit