ONSITE USE ONLY

TEEN SELF-Registration Form
Summer 2025

Please only use this form if you are a teen who is physically at the Neutral Zone while registering. Using this form will also serve as your check-in for today. If you are not at Neutral Zone right now, please use this form instead.

Legitimate contact info for at least one Parent/Guardian/Caregiver is required. We need the information for emergency contacts. We will verify that the contact info is legitimate before a registration will be accepted. A confirmation email and a liability waiver form will be sent to the parent email provided.

If there is a reason you are unable or do not feel safe providing information for a parent or guardian, please contact a staff member and they will help you get registered.

Registrant
Please enter TEEN's information below. All fields with an asterisk* are required. All other fields are optional.
Parent contact information should not be substituted for teen contacts.




                         Please do not use parent email address here

                         If teen does not have their own mobile phone number, do not enter parent phone, leave blank.

Mailing Address

   

Birthdate (MM/DD/YY):  

Pronouns (Check as many as apply):
      
Pronouns - Other: 
For youth who identify as LGBTQIA+, are you out to your parents? (If you do not identify as LGBTQIA+, please skip this question):  

High School (this fall):
      
Specify Other School:  

Estimated Graduation Year:  

Parents /Guardians
Valid contact information for at least one parent or guardian is required for emergencies. It is important that we have at least one adult emergency contact for all teens.

We will NOT accept any registration without an emergency contact.

*Parent/Guardian First Name:  
*Parent/Guardian Last Name:  
*Parent/Guardian Phone:  
                                                Please do not use teen phone number here
*Parent/Guardian Email:  
                                                Please do not use teen email address here
Parent/Guardian Employer:  

Parent/Guardian/Caregiver 2 (Optional)
Parent/Guardian 2 First Name:  
Parent/Guardian 2 Last Name:  
Parent/Guardian 2 Phone:  
Parent/Guardian 2 Email:  
Parent/Guardian 2 Employer:  


Demographics
The following questions are optional, but really helpful to us. Why do we ask? Demographic information reporting is required by some grant funders, so it helps us create reports. We respect your privacy and will never share your personal information without your permission.

Gender (Check as many as apply):
  

Ethnicity (these are not our definitions, they are defined by grant funders. Please select whatever answer seems best to you):

Specify Other Ethnicity:  

Family Income Range:  

Family qualified for MI Bridge benefits?  

Eligible for MI Child Health Insurance?  



If you have any trouble with registration, or want to let us know anything at all, please contact Hananiah Wiggins, Program Director at hananiah@neutral-zone.org or click here

NOTE: Your contact information is confidential and will be NOT shared with any third parties/affiliates for any purposes.