Name:_____                                                                         _ _               ______________

Street Address:  __________________________________     ____                _____________

City:  _____________ Zip:  _______       Home Phone number:  _              _______________

Age:                             Date of Birth:  __________            __        Sex:        Male       Female

Name of Your School:  __                  ____________       ____         Grade: _            ___

Have you been at a Teen Center before?   Yes     No

How did you learn about the Teen Center? Circle all that apply:

Friend    Flyer    Outreach Worker    Parent     Teacher     Law /Police     Other:______  __________________

What attracted you to the Teen Center?  

Programs             Friends            Game Room            Other:______  __________________     __________

I am most interested in: (check all that apply)

___Movies          ___Games          ___Fitness          ___Reading/Studying          ___Help with homework

___Field Trips     ___Music (listening/performing)    ___Other ____                                                       _       

In signing my name below, I agree to abide by the rules and regulations of the Teen Center or forfeit my membership.

Your Signature:  ________________________________________________________

Parent’s Signature:  ________________________________________________________

Date: __________________

  _________Do not fill out below this line. For Official Use Only___________________

Teen Center ID ______________   Date Issued______     ______  Staff Initial                ______                        

Proof of Residency                       _______     OR      Out of Borough Fee          ____      ______       

Staff Signature __   ____                                                     Date       ___  __________ _____