Catawba Teen Center Youth Registration

Youth Information

NAME ___________________________ BIRTHDAY ___/___/_____ AGE ____ SEX ___

RACE _____________ NICKNAME ______________________________
ADDRESS __________________________ _____________ _______ __________
Street Address City State Zip

School Information

CURRENT SCHOOL _________________________ GRADE________

EDUCATIONAL CONCERNS __________________________________________________
________________________________________________________________________
________________________________________________________________________

Guardian Information

GUARDIANS NAME __________________________ PHONE NUMBER ____-____-_______

ADDRESS __________________________ _____________ _______ __________
Street Address City State Zip
RELATIONSHIP TO YOUTH _________________ EMAIL __________________________

Authorized Person to Pick Up Youth

PLEASE LIST ANY PERSON AUTHRORIZED TO PICK UP YOUTH. ID IS REQUIRED IF NOT

REGONIZED BY STAFF

NAME PHONE RELATIONSHIP TO YOUTH

_________________ ____-____-_________ ________________________
_________________ ____-____-_________ ________________________
_________________ ____-____-_________ ________________________
_________________ ____-____-_________ ________________________
_________________ ____-____-_________ ________________________

Catawba Teen Center 996 Avenue of the Nations 803-804-6071

Rock Hill, SC 29730
 Health Information

HEALTH CONCERNS ________________________________________________________

________________________________________________________________________
________________________________________________________________________
MEDICATIONS CURRENTLY TAKEN ____________________________________________
________________________________________________________________________
PRIMARY DOCTOR ____________________ OFFICE NUMBER ____-____-________
ADDRESS __________________________ _____________ _______ __________
Street Address City State Zip
HEALTH INSURANCE COMPANY _________________ POLICY NUMBER________________

Disclaimers/ Waivers

Please check by each box to indicate you understand and agree.

In the event of an major injury that occurs at the teen center, the staff will attempt to
contact the guardian. If the guardian cannot be reached or the injury is believed to be
severe, the staff will call 911 to transport the youth to the hospital. I give the staff
permission to authorize the use of any recommended treatment needed

The Program Coordinator will ask to see youths academic grades at the end of each quarter.
The information will remain confidential and used only for grant reporting purposes.

Youth will be transported by staff in a Catawba Transit vehicle when on trips and from
school. The teen center expects all youth to adhere to transit and teen center rules when
traveling. Failure to do so may result in youth being suspended from traveling with center.

The youth will be traveling with center throughout the year. They are allowed to travel with
the center and are expected to adhere to center rules and staff directions. Failure to do
so may result in youth being suspended from traveling with the center.

If there are any concerns with the staff or site, you will contact the Site Coordinator. If
there are concerns about teen center programs or weekly schedule, you will contact the
Program Coordinator.

You give permission of the teen center to take and publish photos of your youth. They will
only be used to publicize the teen centers events.

I have been made aware of the teen center schedule, understand staff/youth expectations,
understand the discipline/traveling policy, and who to contact with questions.

GUARDIAN SIGNATURE _______________________ DATE_________________

Catawba Teen Center 996 Avenue of the Nations 803-804-6071

Rock Hill, SC 29730