SUMMER@EDGE 2025 Teen Registration Form

Each teen participant only needs to submit once for the entirety of the 2025 Summer Program. This form however does not secure a seat in the EDGE van for the various outings. Please submit and then select which weeks your teen will participate on the original SUMMER@EDGE 2025 page and sign up for each day they will attend. Thank you.

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Name *

First

Last

Age/Grade (Entering Fall 2025) *

School *

Non School Email *

Parent/Guardian Information (Note: We need completed information for at LEAST ONE parent/guardian) *

First name Last name

Relationship *

Home Phone

Cell Phone *

Name

First

Last

Relationship

Home Phone

Cell Phone

Medical Information *

Allergies/Conditions/Medications

Primary Doctor *

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. *

Parent/Guardian Signature

Photo Release *

• 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.

Gender *

• Female
• Male
• Prefer not to answer

Demographics (This information is necessary for the funding of our program. All information will be kept confidential)

Race/Ethnicity (Select all that apply) *

• American Indian or Alaska Native
• Asian
• Black or African American
• Hispanic or Latino
• Native Hawaiian or Other Pacific Islander
• White
• Other

Demographics (This information is necessary for the funding of our program. All information will be kept confidential)

Annual Household Income *

• $0-$15,650
• $15,651-$21,150
• $21,151- $26,650
• $26,651-$32,150
• $32,151-$37,650
• $37,651-$43,150
• $43,151- $48,650
• $48,651+

Demographics (This information is necessary for the funding of our program. All information will be kept confidential)

Total # of Individual in the Household *

Demographics (This information is necessary for funding our program. All Information will be kept confidential)

2025 Summer Program REGISTRATION FORM, PREVENTION ACTIVITY & COMMUNITY SERVICE PARTICIPATION & RELEASE AGREEMENT: By signing 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 2025 Summer@EDGE programs and indemnify, release, agree not to sue, and discharge EDGE Teen Center and their agents, for liability and all costs arising from your teenager’s participation in these 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 physical labor, prevention based activities, college campus tours and 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 Teen Center in writing, we believe your teenager has your approval to participate fully. AGREED TO: *

Participant’s Name

Participant Electronic Signature *

Parent/Guardian Electronic Signature *

Submit