Club Connections Waitlist : Club Connections : Programs : What We Do : Club 21 Learning and Resource Center

Teen/Young Adult's Name:

Age

Gender

Address:

City

Zip Code

Birthday

Would you like to be contacted in addition to your parents?

If yes, please provide your email and phone number below

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Teen's Email

Teen's Phone Number:

Parent's Name

Parent's E-mail:

Parent's Phone

Have you participated in Club Connections before?

Name of High School, College, or Program Students Attends

Grade of Student

Allergies to Food (If none, type "N/A")

Allergies to Meds (if none, type "N/A")

Current Meds (and dosage)

Special Diet:

If "other" please indicate what that is:

Any difficulty with sight or hearing?

If yes, please indicate what those are:

What is your teen's main method of communication?

Does your teen have any behavioral triggers or are there any situations that would require further assistant/intervention?

Please explain your teen's reading comprehension and written expression

Club 21 Member?

Does Club 21 have permission to release photos of your teen:

by clicking "yes" you give your consent

Club Connections Waitlist