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Teen Registration

Please print and either bring to the first meeting or mail this form to:
CJL, 194 Jackson St, Northampton, MA 01060  (Checks payable to CJL) OR Pay Here 

 
Student Name: ____________________________________________________

School: ___________________________________________________________

Grade in September: ______

Parent 1 name: ____________________________________________________

Address: __________________________________________________________

Cell Phone:  _____________________ E-mail: ____________________________

Parent 2 name: ____________________________________________________

Address: __________________________________________________________

Cell Phone:  _____________________ E-mail: ____________________________


EMERGENCY CONTACT INFORMATION:

Name: ___________________________________________________________

Phone number:   ___________________________________________________

Relationship to student_______________________________________________

Family Physician ___________________________________________________

Phone____________________________________________________________

Medical Insurance Provider: __________________________________________

Group or ID #: ______________________________________________________

I hereby give consent to CJL to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.), osteopath (D.O.), or dentist (D.D.S.) for my teen. This care may be given under whatever conditions are necessary to preserve life, limb, or well being of the teen named above. 

I understand that I will be contacted immediately, as will my child's physician.

Parent signature: ________________________________________  Date: ____________________

ADDITIONAL INFORMATION:

1.  Does your child have any allergies or other medical condition we should be aware of?  



2.  Please describe any learning challenges or special needs.
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3.  I give permission for photos taken during CJL to be used on the CJL website or in flyers advertising our programs.  The student's name will not be attached to any photo.    Yes______     No ______

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