2025 School Program Membership Form

Child's Name

Address

Child's Email

Child's Phone Number

Grade

Name of School

Date of Birth

Gender

How did you hear about Teen Haven?

I attended Teen Haven before today I attended Wonder Academy (previously Wonder Club) A friend invited me Water Street Mission Event Childs School

Parent/Guardian Information

Parent/Guardian Name and Relationship

Parent's Phone

Parent's Email

This address will receive a confirmation email

Emergency Contact

Emergency Contact Phone number

Allergies

Does child have any allergies?

Yes No

Known Allergies:

Egg Fish/Shellfish Insect Stings (ex: bees, wasps, etc.) Latex Medications Milk/Dairy Nuts Soy Wheat/Gluten

Please list additional allergy information here.

Medical Contact

Name of Primary Physician/Clinic

Physician/Clinic Phone number

Medical Insurance Company

Policy number

Consent & Release form

As parent or legal guardian of the above named student, I give my permission for my child to attend Teen Haven programs. I do hereby release and indemnify Teen Haven and/or Water Street Ministries of any and all responsibility resulting from injuries, which may be obtained by my child in route to or from, or while at Teen Haven programs. I give my consent for a Teen Haven staff member to directly contact my child via text message or social media concerning Teen Haven activities and events. I hereby give Teen Haven staff and/or volunteer’s full permission and authorization to secure emergency medical treatment for my child at the hospital of their choice in the case of an emergency. I also authorized that hospital to provide any and all necessary treatments. I understand the likeness of my child may appear in program/activity photographs and permit Teen Haven to use said likeness in any printed materials, online publications, or videos used solely for its nonprofit purposes. I understand Teen Haven staff and volunteers must have an active role in the discipline of my child while he/she is involved in Teen Haven programs. I will support the staff and volunteers in their supervisory efforts.

Signature

Date

2025 School Program Membership Form

Description

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