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.
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 ______
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.
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 ______
