Bridgeton High School Teen Center Registration Form

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
Patient Name
Date of birth

MonthDayYear
Date
Sex

MaleFemale
Ethnicity (Check all that apply)

Black/Non-HispanicHispanic/LatinoWhite/Non-HispanicAsian AmericanMulti-RacialOther
Social security #
Telephone
Address
Name of Parent or Legal Guardian
Emergency Contacts: Who should we contact in case of emergency?
Name
Telephone #
Work#
Cellular#
Name
Telephone #
Work#
Cellular#
Are you currently enrolled in school?

YesNo
If yes, current grade
If no, last grade completed
Dropped Out of School?

YesNo
Special Education?

YesNo
Graduated from school?

YesNo
Who referred you to this center? (Check One)

SelfParent/StepparentOther Family MemberFriend/School MateTeacherGuidance StaffSomeone ElseJuvenile Justice StaffHuman Services Agency School NurseSchool NurseOther School Staff
What adults do you live with you right now? (Check all that apply)

MotherFatherStepmotherStepfatherGrandmotherGrandfatherOtherNo Adults
Are you currently a patient at CompleteCare Health Network?

YesNo
Are you receiving State services, like NJ Family Care?

YesNo
Do you have a primary provider?

YesNo
Name of Provider
Do you have medical insurance?

YesNo
Name of insurer:
Insurance ID #:
Group #:
Name of insured:
Social Security # of Insured:
Date of Birth of Insured

MonthDayYear
Date
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.
Signature of Patient/Guardian

Clear
Date

MonthDayYear
Date
Should be Empty: