EJS Project Teen Center Enrollment

Gender

Male Female Prefer not to say Prefer to self-describe (below)

If you selected "prefer to self-describe," please enter your response here:

Parent/Guardian Information

Other Emergency Contact

Medications/Conditions

Household Information

This section must be completed. It is necessary for the funding our organization receives. All information is entirely confidential.

Race of teen:

Teen qualifies for free/reduced lunch?

Yes No

Teen lives with (check all that apply):

Single parent

Yes No

Mother's highest level of education:

Father's highest level of education:

I give my permission for EJS Project to use photos and/or videos that include my child on its social media sites and website, and in publications, printed materials and local media.

I give permission for my teen to access his/her grades and school records while in the presence of EJS staff and volunteers. I also give EJS Project and my child’s school permission to exchange information regarding my teen. The purpose of this exchange is to help both organizations more effectively support the teen’s academic goals.

Best school contact (teacher/advisor):

Does your child have an Individualized Education Plan (IEP)?

Yes No

Please use the space below to provide details or list educational and social-emotional goals you would like to share with us:

My child has permission to walk home alone at dismissal:

Yes No

My child MAY NOT be picked up by:

The following individuals are authorized to pick up my child:

By submitting this form, you give your student permission to attend EJS Project Teen’s Center and acknowledge that you have reviewed and understand the Code of Conduct regarding your student’s participation.