East Student Registration 2023-2024

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Student Information

Name
Date of Birth
Home Address

Parent/Guardian Information

(NOTE: We must have complete information for at least one parent/guardian.)
Name (1)
Name (2)

Other Emergency Contact

Name

Medical Information

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.
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.

Demographics

(This section must be completed. It is necessary for the funding our organization receives. All information is kept confidential.)
Student Lives With (check all that apply)
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.
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.
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.
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
A licensed counselor from Focus On Youth is at EDGE@East 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

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.
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.