Teen Group Registration Form

(grades 9-12)

Parent/Guardian Full Name

Email

Phone

Name of Youth & Pronouns

Youth Birthday

Month

Day

Year

Address

List any allergies, N/A if none

Please share anything that may help us when working with your child.

Please list any adults (full name to match ID) here along with their phone numbers who are approved to pick your child up from group. If only you please mark that.

By checking this box you acknowledge that transportation to and from group is the parents/guardians responsibility and Centre LGBT+ is not responsible if your youth leaves group for any reason. Any approved adults you list on this form should bring their ID's with them when picking your child up.