Please print the Registration Form and mail a completed copy, along with the completed Release Forms, to Generation Xcel, 9 East 7th Street, New York, NY 10003, or fax them to 212-673-5595.

X-PRESS
REGISTRATION FORM

Teen’s Name
Last _____________________________
First ______________________________
M.I. ______

Sex (M/F) ______  
Birthdate ____/ ____/ ____           
Age ______   

Address
Street __________________________
Apt. _____
City _______________
State ___________
Zip_________

Phone (Home) _________________

Parent/ Guardian _______________________________

Address
Street __________________________
Apt. _____
City _______________
State ___________
Zip _________

Phone (Home) _________________ 
(Work) ___________________

Name of School: __________________________________________________________

School Grade, Fall Semester ____________________

Grade Point Average: ______________________

Does student suffer from a special disability or disease (HIV/AIDS, Diabetes, Epilepsy, Dislexia, Asthma, ADD, Cancer, etc.)?  (Y/N) _____. If yes, please specify: ______________________________________

_____________________________________________________________________________________

Is the student classified as special education or does s/he attend an alternative high school program? (Y/N) ____. If yes, please specify: ____________________________________________________________ 

_____________________________________________________________________________________

Is the student currently on any medication or other regular treatment that may require supervision? (Y/N) _____.  If yes, please specify: ____________________________________________________________ 

_____________________________________________________________________________________

When departing for the day, is the student permitted by the parent/guardian to leave the 88-Step Theater by one's self, without being picked up by an adult? (Y/N) _______________________________

Will the student be dropped off at the premises and picked up? (Y/N) ______.  If yes please specify the name (s) of the individual(s) with whom the student is allowed to leave the premises: ___________________________________

_____________________________________________________________________________________

In case of an emergency is Generation Xcel staff permitted to take immediate action, such as calling 911, or accompanying the child to the emergency room or other health care facility? (Y/N)____________

SECONDARY FAMILY MEMBER OR NEIGHBOR TO NOTIFY IN CASE OF EMERGENCY:

Name  _________________________________________________

Emergency Phone  ____________________________

Address
Street __________________________
Apt. _____
City _______________
State ___________
Zip _________