EJS Project Teen Center EnrollmentEJS Project Teen Center Enrollment Student Information First Name Last Name Date of Birth Grade School Gender Male Female Prefer not to say Prefer to self-describe (below) If you selected "prefer to self-describe," please enter your response here: Student Email Home Phone Cell Phone Home Address City State Zip Code Parent/Guardian Information First Name Last Name Relationship Email Cell Phone Work Phone Place of Employment Other Emergency Contact Phone Medical Information Medications/Conditions Allergies Primary Doctor Phone Household Information This section must be completed. It is necessary for the funding our organization receives. All information is entirely confidential. Race of teen: African American Asian Caucasian Hispanic Native American Other Country of Origin Primary Language Teen qualifies for free/reduced lunch? Yes No Teen lives with (check all that apply): Mother Father Stepmother Stepfather Grandparent Guardian Other Single parent Yes No Mother's highest level of education: Father's highest level of education: Photo Release Yes No 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.Academics Yes No 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:Dismissal 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: Name/Relationship Phone Address Name/Relationship Phone Address 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. Send
