SquadGoals Registration Form

SquadGoals Teen Studio Registration Form

Fill out the form carefully for registration
Youth 's Legal Name

First NameMiddle NameLast Name
Nickname
Birth Date

MonthDayYear
Age
Gender
Race/Ethnicty
Preferred Pronouns
Last 4 of SSN
Duval County School ID#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
School Name
Current Grade Level
Student ID (Numbers Only. Do not include the 'S')
Parent/Guardian Name
Parent/Guardian E-mail
Parent/Guardian Phone Number

Area CodePhone Number
How did you hear about this program?
#SquadGoals Teen Studio

This program is available every day Monday through Friday. Participants must commit to a minimum of two (2) days a week, but can select as many as five (5). Class sizes are limited and attendance is important. Preference will be given to those who are committed to 5 days a week
Arts Area(s) of Interest (Select all that apply)
Primary Discipline/Area of Interest
Secondary Discipline
I am interested in attending the following days (Must pick at least 2):
List any medications the youth is prescribed including dosage and frequency:
List any allergies the youth may have:
List any dietary restrictions the youth may have:
Are there any problem areas the JaxTPA staff should be aware of? (such as behaviors, fears, etc.)
Does the youth have a history of delinquency?
If yes, please explain the history of delinquency including the date of the last incident. If no, please enter N/A if not applicable:
Does the youth have a history of aggressive behavior?
If yes, please give examples of the aggressive behavior. If no, please enter N/A if not applicable:
Does the youth have a history of running away?
If yes, please explain the history. If no, please enter N/A if not applicable:
How does the youth get along with adults/authority figures?
How does the youth get along with peers (social skills, leader/follower, etc.)?
Please list any special needs the youth may require.
Review and Sign

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Name

First NameLast Name
Date

MonthDayYear
Date
Relationship To Youth
If Other, Please Specify
Emergency Contact Information
This number should be for the on-call person who will be responsible for taking any incident reports regarding youth or to pick up youth if absolutely necessary.
Contact For Insurance
Please fill out the following if applicable:
Name of CBC Case Manager
Case Management Organization
Case Manager Office Phone
Case Manager Cell Phone
Case Manager Email Address
Case Management Agency On-Call Contact
Should be Empty:

SquadGoals Teen Studio Registration Form

#SquadGoals Teen Studio

Review and Sign