Teen Health Class: Registration

This class is general health education for teens. It is not a medical appointment.

1. Participant Information

2. Parent / Guardian Information

3. Emergency Contact

Please provide someone other than the parent/guardian listed above.

4. Attendance

5. Scheduling Preferences

6. A Few Questions Before the Class

These help us tailor the session. All questions are optional. There will also be a chance to write down questions anonymously at the start of class.

7. How Did You Hear About This Class?

8. Optional

9. Consent and Acknowledgment

Please read carefully before signing.

Educational purpose. This class is general health education. It is not a medical appointment, does not create a patient–provider relationship, and is not a substitute for individual medical advice. No physical exams are performed and no medical records are created. For personal medical questions, please schedule an appointment.

Privacy. The information on this form is used only to register for and run this class. It is not added to a medical record. It is stored securely and is not sold or shared outside Grace Health.

Group setting. Class discussion takes place in a group. We ask all participants to keep what others share private, but we cannot guarantee it.

Permission to participate. I am the parent or legal guardian of the participant named above, and I give permission for her to attend this class.

Participation Consent

By typing your name below, you confirm that you have read and agree to the above terms, and that you give permission for the participant to attend this class. Typing your name constitutes your signature.

Media Release (optional)

If you consent to Grace Health using photos or videos of the participant taken during class for educational or promotional purposes, please sign below. This is separate from the participation consent above and is entirely optional. Your teen can attend the class whether or not you sign here.

By typing your name below, you give Grace Health permission to use photos or videos of the participant for educational or promotional purposes. Typing your name constitutes your signature.