Teen Registration Form
Summer 2026

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. DO NOT LEAVE PARENT INFO BLANK, YOU WILL NOT BE 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.



  Do not use parent email address here
   Do not enter parent phone here

Mailing Address
   (e.g. 123 S Main St)
   

*Estimated Graduation Year:  
Birthdate (MM/DD/YY):  

Pronouns: 
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:
      
Other School (if not listed above):  

Parents /Guardians
Valid phone AND email 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:            Do not use teen phone number here
*Parent/Guardian Email:              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?  



By signing my student up, I authorize this program to collect and use data about my child for the purposes of program development, safety, and improving educational outcomes. I understand that this data will be kept confidential, stored securely, and used by authorized personnel within the organization, and shared with Michigan Department of Lifelong Education, Advancement, and Potential (MiLEAP) 32n OST Grants Program and state evaluation partners.

NOTE: We do not share full names, pronouns, gender, or contact information for this or any other purpose, only the teen's first name, last initial, and approximate graduation year -- and only for the one grant that requires this. Please contact us if you have any concerns.

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