North Midland Family Center
TEEN INFORMATION RECORD

Date:

Name of Child:                                                     Date of Birth:                         Grade in School:

Home Address:                                                            City:                                           State/Zip:

Mother/Legal Guardian's Name:                        Home Phone:                                    Cell Phone:

Father/Legal Guardian's Name:                          Home Phone:                                    Cell Phone:

Emergency Contact Name:                                  Home Phone:                                    Cell Phone:

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I give permission to North Midland Family Center, licensed by the Department of Consumer and Industry Services to secure emergency medical and/or surgical treatment for the above named minor child while in care.

__________________________________________                        _______________________
            Signature of Parent or Guardian                                                        Date Signed

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Allergies:

______________________________________________________________________________________

Permission to Photograph?                               Permission to Photograph for Publicity Purposes:

      Yes                  No                                                                        Yes                        No

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__________________________________________                        _______________________
            Signature of Parent or Guardian                                                        Date Signed