Application Form

All sections with a red asterisk is required for submission. For items where information doesn't apply, type in "None".

Student Information

First Name: *

Last Name: *

Date of Birth: *

Gender: *

Grade: *

School: *

Home Address: *

City: *

State: *

Zip Code: *

Home Phone #: *

Cell Phone #: *

Student Email: *

Parent/Guardian Information #1

Name: *

Relationship: *

Email: *

Cell Phone #: *

Work Phone #: *

Place of Employment: *

Parent/Guardian Information #2

Name:

Relationship:

Email:

Cell Phone #:

Work Phone #:

Place of Employment:

Medical Information

Medications: *

Allergies: *

Primary Doctor: *

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: *

Parent/Guardian Signature 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

Household Income: * $0-$15,630 $15,631-$21,060 $21,061-$26,490 $26,491-$31,920 $31,921-$37,350 $37,351-$42,780 $42,781-$48,210 $48,211-$53,640 $53,641 +

Member Lives With (check all that apply): * Both Parents Mother(s) Father(s) Step Mom Step Dad Grandparent(s) Guardian(s) Foster Family Other

Number of individuals in household: *

Teen qualifies for free/reduced lunch: * Yes No

Language spoken at home: *

Photo Release: *
Yes No I give my permission for Forest Park Ohio 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.

Academics: *
Yes No I give permission for my teen to access his/her/their Home Access Center (HAC) and CANVAS account while in the presence of Forest Park Ohio Teen Centers staff/adult volunteers. I also give Forest Park Ohio 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 teen’s academic goals.

Physical Education and Activity: *
Yes No I give permission for my teen to participate in physical education and physical activities provided by Forest Park Ohio Teen Center. Specifically, I understand that Forest Park Ohio Teen Center may contract with outside instructors to lead these activities for the benefit of my teen. By signing, I waive any cause of action against Forest Park Ohio Teen Center and the instructor of any activity sanctioned by Forest Park Ohio 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.

Behavioral Health:

A licensed counselor from NAMI will help at Forest Park Ohio Teen Center 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.

______ I have completed the attached “consent for treatment” counseling form.

Student Registration Form

Student Information

Parent/Guardian Information #1

Parent/Guardian Information #2

Medical Information

Demographics