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

Month Day Year
Date
Sex

Male Female
Ethnicity (Check all that apply)

Black/Non-Hispanic Hispanic/Latino White/Non-Hispanic Asian American Multi-Racial Other
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?

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

Yes No
Special Education?

Yes No
Graduated from school?

Yes No
Who referred you to this center? (Check One)

Self Parent/Stepparent Other Family Member Friend/School Mate Teacher Guidance Staff Someone Else Juvenile Justice Staff Human Services Agency School Nurse School Nurse Other School Staff
What adults do you live with you right now? (Check all that apply)

Mother Father Stepmother Stepfather Grandmother Grandfather Other No Adults
Are you currently a patient at CompleteCare Health Network?

Yes No
Are you receiving State services, like NJ Family Care?

Yes No
Do you have a primary provider?

Yes No
Name of Provider
Do you have medical insurance?

Yes No
Name of insurer:
Insurance ID #:
Group #:
Name of insured:
Social Security # of Insured:
Date of Birth of Insured

Month Day Year
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

Month Day Year
Date
Should be Empty: