CTeen Member Registration

Address*

Teen's Gender*

MaleFemaleNon-Binary
Teen's Birth Date*

Month Day Year
Time of Birth: Before Sunset?*

YesNoUnknown
Current Grade Level*
Teen's Email Address
Teen's Cell Phone Number
Emergency Contact Name*
First Name Last Name
Emergency Contact Phone Number*
Medical Consent
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.*
As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of CTeen to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, CTeen personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in CTeen activities and that these pictures may be used for marketing purposes. By submitting this form I acknowledge and agree to the terms and conditions
I Accept*

Yes
Full Name*
First Name Last Name
Initial Here*
I would like to receive news and updates by email
Should be Empty:

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Medical Consent