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SWAG House Registration
The following questions are to be answered by the teen participant.
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* Indicates required question
Legal Name
*
Your answer
Preferred Name
Your answer
Preferred Pronouns
*
she/her/hers
he/his
they/them/theirs
Other:
Phone Number
*
Your answer
Is texting okay?
*
Yes
No
Date of Birth
*
MM
/
DD
/
YYYY
Home Address (including city)
*
Your answer
Race
Your answer
Allergies
*
Your answer
Dietary Restriction(s)
*
Your answer
Special Interests/Skills
*
Your answer
What school do you go to?
*
Option 1
What grade are you in?
*
6th
7th
8th
9th
10th
11th
12th
How do you plan to get to SWAG House?
*
Your answer
Anything else you want us to know?
Your answer
Did you read and understand all of the SWAG House rules? (Available on the website)
*
Yes
No
The following questions are about the Parent(s)/Guardian(s)
Parent/Guardian Name(s)
*
Your answer
Parent/Guardian Phone number(s)
*
Your answer
Is texting okay?
*
Yes
No
Emergency Contact (Besides Parent or Guardian already listed)
*
Your answer
Emergency Contact Phone Number
*
Your answer
The following people may NOT pick up my teen
*
Your answer
Parent/Guardians, can your teen drive themselves home?
*
Yes
No
Other:
Parent/Guardian, what should we know about your teen?
Your answer
Parent/Guardian, Please consent to the following
*
SWAG House may treat my child with necessary CPR and first aid
SWAG House may call 911 and have teen transported by Ambulance
SWAG House may administer ibuprofen, aspirin or Tylenol as requested or needed.
Required
If there is a choice, which medical center would you like to have your teen transported to?
*
Your answer
The following questions are for funding purposes only. Please answer any that you are comfortable answering. All answers will be kept confidential.
How many people aged birth-18 live in your home?
Your answer
How many people over 18 live in your home?
Your answer
Do you rent or own your home?
rent
own
Other:
Clear selection
What is your teen's GPA?
Your answer
What is your race
Option 1
Clear selection
Do you qualify for government assistance?
Yes
No
Other:
Clear selection
Thank you for registering for SWAG House!
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