Teen Center Enrollment Form

Please fill out the form below (one per child) and then submit. You must answer the last question about the name of the town with "Sudbury" otherwise, the form will not be submitted. This is to prevent bots from sending spam via this form. If you have another child to register just click on the continue link to fill out another form.

Child's Information

First Name

Middle Initial

Last Name

Street Address

Home Phone ex. (978) 443-1234

Other address/Phone where child also lives

(Response character length limit: 5000; remaining: )

Gender

• (No choice selected.)
• Male
• Female

Grade in 2009-10

• (No choice selected.)
• Grade 7
• Grade 8

Birth Date

Allergies/Medications/Health Issues

(Response character length limit: 5000; remaining: )

Emergency Contact Information

Parent/Guardian Name(s)

Email Address (for monthly event information & updates)

Cell Phone Number (First)

Cell Phone Number (Second)

Home Phone (if different from child)

Relationship

If Parent/Guardian cannot be reached

Name

Relationship

Home Phone

Cell Phone

The parents and teen acknowledge that participation at Teen Center events and special theme nights involves physical activity, which could result in possible injuries. The parents and teen certify that there is health insurance in full force and affect insuring all necessary medical treatment. The parents hereby agree to indemnify and hold the Town harmless for any claims, actions or costs resulting from the child's participation in the activities and while travelling to and from home.

Please answer the following question before sending your responses.

What is the name of this town?