Teen Challenge Tasmania Referral Form
This is an enrolment form to participate in Teen Challenge - Youth Events/Activities like Games afternoon etc
Participant First Name
*
Participant Surname
*
Date of Birth
*
Gender
Enrolment for Child or Adult
*
Child - Under 18
Adult - Over 18
Referee
*
Parent
Caregiver
Guardian
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Participants Details
Participant Contact Email Address
*
example@example.com
Participant Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade
*
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Other
School Name
*
Struggles you are currently facing:
*
Stress
Anxiety
Relationships
Depression
Anxiety/Depression
None
Other
Which Youth Activitiy are you interested in?
*
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Parent/Guardian/Caregiver Information
Parent/Guardian/Caregivers 1 Name
*
First Name
Last Name
Parent/Guardian 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1 Email
*
example@example.com
Parent/Guardian/Caregivers 2 Name
First Name
Last Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Email
example@example.com
Does the participant live with
*
Parent/Guardian One
Parent/Guardian Two
Both
Are there any court orders in place?
*
Yes
No
Is there anything else you would like to let us know in this area?
ie How they are to arrive/get home etc? Who can collect them etc?
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Emergency and Medical Information
Emergency Contact Name
*
Emergency Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any Medical or Health issues.
Please list any allergies and/or medication. We supply some light refreshments so dietry requirements would be good to know too.
Are there any treatments undertaken for any of the above? If so please let us know
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Further Information & Session Preference
Area's you would like to focus on: (ie expressing feelings,......)
Any Information or thoughts that may assist Team members help this being more enjoyable for your child:
How did you hear about Teen Challenge Youth Events/Activities?
*
Website
Teen Challenge Team
Hope Costumes & Thrift
School
NJL
A Meaningful Art Participant
Teen Challenge Newsletter
Hope Cafe
Other
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Terms & Conditions and Permissions
Signature
*
Date
*
/
Day
/
Month
Year
I give permission for myself/my child to be photographed during the youth program, as long as I am aware each time this takes place
*
Yes
No
I give permission for photographs of my art work to be used for Teen Challenge Tasmania records
*
Yes
No
I give permission for any photographs of myself/my child and/or art work to be used for Teen Challenge Tasmania's promotion or public viewing
*
Yes to both myself & my artwork
Yes to my artwork only
Yes to myself only
No
Signature
*
Date
*
/
Day
/
Month
Year
Submit
Should be Empty: