Student Registration Form

Student Registration Form

The Santiam Teen Center requires each student who participates in activities and events is registered by a parent or guardian. The following information should be provided by the parent or guardian and then updated as necessary. All the information will be kept confidential. *The parent/ guardian will be contacted to verify the information given.
Name*

First Name (legal)Preferred NameLast Name
Birthdate*

MonthDayYear
Date
Age*
MaleFemale
School Attending*
Grade (2024-25)*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Teen Email*
example@example.com
Teen Cell Phone

Area CodePhone Number
Student Medical Information
Current or past medical conditions our staff should be aware of
Allergies*
Any medications staff should be aware of
YesNo
Parent/Guardian*

First NameLast Name
Relationship to Participant*
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Email*
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person – Other than Parent/Guardian Listed Above *

First NameLast Name
Relationship to Participant*
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
SANTIAM TEEN CENTER Code of Conduct and Neutral Zone Policy
Our Code of Conduct and Neutral Zone policy includes but is not limited to:
1. Upon arrival at the Santiam Youth Center, I must sign in with a staff member.
2. I will sign out with a staff member upon departure from the Youth Center and understand that my family and I are responsible for my transportation home. Staff/Volunteers are never allowed to drive students home unless written approval from the parent.
3. I will Be responsible for my own behavior/conduct.
4. I will support and abide by the Teen Center staff/volunteers rules and follow their directions.
5. I will be honest and trustworthy in my participation at the Teen Center and try hard to keep a positive attitude.
6. I will show respect to others, peers and adults, by being courteous and kind.
7. I will not intimidate, bully, put others down or be disrespectful in any way. I will not threaten any violence, written, typed, spoken or “getting in someone’s face”. No posturing/physical intimidation: following someone outside and being physically threatening. This includes offensive and intimidating language.
8. No weapons of any kind are permitted: no guns, knives or other weapons.
9. No smoking/tobacco: Smoking or using tobacco products in, on, or within the surrounding area of the Santiam Teen Center’s property.
10. No gang, drug, tobacco or alcohol clothing, symbols or other expressions.
11. I will be free from the possession and consumption of drugs, alcohol and tobacco, or perceived to be under the influence of drugs or alcohol. Including drug dealing/possession of drugs at the Teen Center or within a two block radius. This includes actions or statements which give the appearance of doing so.
12. I will use appropriate language: I will not swear or use insulting, vulgar or offensive language.
13. I will refrain from possession of fireworks and other flammable objects, including matches/lighters.
14. I will abide by the Teen Center “hands off” policy. I will not partake in sexual behavior in the Teen Center.
15. I will be respectful of Teen Center property, no intentional destruction of property or graffiti. I will use materials and equipment in a safe manner so items are not damaged or lost. If I break or damage something in a purposeful manner, I am responsible to replace it.
16. I will be respectful of students and staff property. I will not not steal or borrow anything without the owner’s permission.
17. I will report any problems or issues, including issues with others and their behavior, to the staff/volunteer. I will ask for their help and communicate my needs with them.
18. I will accept the consequences for my inappropriate behavior
The Santiam Teen Center is a Neutral Zone for all youth, staff and volunteers. No hate, harassment, intimidation, or discrimination are allowed on the premises at any time. The Teen Center is open for all youth regardless of Color, Creed, Faith, Sexual Orientation, Lifestyle, etc. You are expected to respect EVERYONE while you are here. Behaviors which violate the Neutral Zone will result in consequences at the staff’s discretion. Repeated inappropriate behavior will result in dismissal from the premises.*

I have read, understand and pledge to follow these standards of behavior in order to make the Santiam Teen Center a safe, fun, and positive environment, for myself and for all members of the Santiam Teen Center.
Santiam Teen Center Discipline Procedures

The progressive discipline procedures*** is divided into two sections, common behavior infractions and criminal activity. The first consequence listed is for first time offenses, the second/third consequence is for on-going and repeated infractions.
1. Inappropriate language: (1) verbal warning, (2) written notification, (3) call home and asked to leave.
2. Inappropriate wardrobe: (1) verbal warning, (2) written notification and asked to leave until dressed appropriately.
3. Inappropriate computer use: (1) verbal warning, (2) written notification and removal from computer, (3) call home and asked to leave.
4. Public displays of affection (kissing, sitting on laps, etc): (1) verbal warning, (2) written notification (3) call home and will be asked to leave.
5. Not following staff/volunteer directions: (1) verbal warning, (2) written notification and asked to leave, (3) call home and multiple days’ suspension.
6. Being disrespectful to staff/volunteers and others: (1) written notification and asked to leave, (2) call home and multiple days suspension.
7. Possession of tobacco, lighter, or fireworks, etc. (1) written notification and asked to leave, (2) call home and multiple days suspension.
8. Smoking or use of tobacco: (1) written notification and asked to leave, (2) call home and multiple days suspension.
9. Possession of any weapons: (1) written notification and asked to leave, (2) call home and multiple days suspension.
The following are crimes. Parents and the police department will be notified.
1. Bullying, verbal, cyber, or physical.
2. Destruction of property and vandalism.
3. Gambling.
4. Violence, fighting.
5. Possession or under the influence of drugs or alcohol.
6. Selling or purchasing controlled substances (including drugs).
Yes
SANTIAM TEEN CENTER 2024-2025 WAIVER

I accept responsibility for sending my child to THE SANTIAM TEEN CENTER, acknowledging that activity at THE SANTIAM TEEN CENTER involves risk and may result in varying types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease (including Covid-19), bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

I authorize the staff on duty at THE SANTIAM TEEN CENTER to administer first aid as required. In case of an emergency, I understand that every effort will be made to contact me. However, if I cannot be reached, I hereby give permission to the physician or dentist selected by THE SANTIAM TEEN CENTER to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child.

In consideration for the opportunity to participate in activity at THE SANTIAM TEEN CENTER the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity, as well as for any medical treatment rendered to the participant.

I voluntarily waive any claim against THE SANTIAM TEEN CENTER, personnel, volunteers or other person(s) against all liability, claims, damages, attorney fees, and expenses arising out of, or in connection with, any activities of the above organization.
Yes
YesNo
YesNo
Parent/guardian Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

SANTIAM TEEN CENTER Code of Conduct and Neutral Zone Policy

Our Code of Conduct and Neutral Zone policy includes but is not limited to:

Santiam Teen Center Discipline Procedures

SANTIAM TEEN CENTER 2024-2025 WAIVER