• Bridgeton High School Teen Center

    A School-Based Youth Services Program
  • 111 N. West Avenue • Bridgeton, NJ 08302 • P: 856-451-4440 • F: 856-451-4815
    Counseling • Healthcare • Enrichment • Employment • Education

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  • Emergency Contacts: Who should we contact in case of emergency?

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  • I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my provider or any other member of his/her staff responsible for any error or omissions that I may have made in the completion of this form, as well the medical history form. I will inform the staff at the Teen Center and CompleteCare Health Network of any changes. I give permission for care and treatment and give permission to bill my insurance.

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