Teen Registration Form
School Year 2023-24

Parent/Guardian contact info is required. We need the information for at least one parent, guardian or adult caregiver for emergencies. A confirmation email and a liability waiver form will be sent to the parent email provided.

You do NOT need to specify which programs you want to join. Come any day you like! You will be added to the roster the first time you attend the program.

Registrant
Please enter TEEN's information below. All fields with an asterisk* are required.



Please do not use parent email address in this field

If teen does not have a phone number, please do not enter parent phone

   

Birthdate (MM/DD/YY):  

Pronouns (Check as many as apply):
      
Pronouns - Other:
For youth who identify as LGBTQIA+, are you out to your parents? (If you do not identify as LGBTQIA+, please skip this question):  

High School (this fall):
      
Specify Other School:  

Estimated Graduation Year:  

Parent/Guardian/Caregiver
Full contact information for at least one parent or guardian is required. It is important that we have at least one adult emergency contact for all teens.

*Parent/Guardian First Name:  
*Parent/Guardian Last Name:  
*Parent/Guardian Phone Number:  
*Parent/Guardian Email:  
Please do not use teen email address here
Parent/Guardian Employer:  

Parent/Guardian/Caregiver 2
Parent/Guardian 2 First Name:  
Parent/Guardian 2 Last Name:  
Parent/Guardian 2 Phone Number:  
Parent/Guardian 2 Email:  
Parent/Guardian 2 Employer:  


Demographics
The following questions are optional, but really helpful to us. Why do we ask? Demographic information reporting is required by some grant funders, so it helps us create reports. We respect your privacy and will never share your personal information without your permission.

Gender (Check as many as apply):
  

Ethnicity (these are not our definitions, they are defined by grant funders. Please select whatever answer seems best to you):

Specify Other Ethnicity:  

Family Income Range:  

Family qualified for MI Bridge benefits?  

Eligible for MI Child Health Insurance?  



If you have any trouble with registration, or want to let us know anything at all, please contact Hananiah Wiggins, Program Director at hananiah@neutral-zone.org or click here