New Student Registration

STUDENT APPLICATION FORM

At The Motivational Edge, we believe that our talented, creative, and passionate team possesses the drive and the unyielding and endearing attitude that is needed while serving diverse populations. Our team strives to earn the trust of our students and families and the public through hard work, progressive and effective programming, ethical conduct, and responsible service.

STUDENT REFERRAL FORM

The following referral form should be completed as much as possible

before the student begins services.

For Inquiries or Emergencies, please contact The Motivational Edge campus at

786-637-2143 or admin@themotivationaledge.org

(If not, we may be able to help you find affordable coverage – call 211 or visit

www.thechildrenstrust.org/parents/health-connect/insurance.)

We want to get to know your child better so that we can provide the best possible experience in our programs. Please tell us more about your child…

If you are interested in other services funded by The Children’s Trust,
please call 211 or visit www.thechildrenstrust.org. For special needs resources for your child, visit www.advocacynetwork.org or www.thechildrenstrust.org/content/children-disabilities.

Please enter the name, relationship to the youth, and the phone number

for anyone approved to pick up your child:

the staff of The Motivational Edge and/or its funded service providers to take/use still photographs, digital photographs, motion pictures, television transmissions and/or videotaped recordings (hereinafter “Recordings”) of me, my children or my wards for educational, research, documentary and public relations purposes.

Any such Recordings may reveal your identity through the image itself without any compensation to you, your children, or wards.

Any and all Recordings taken of you, your children or wards shall be the sole property of The Motivational Edge and its funded service providers.

With regard to the use of any Recordings taken of you, your children or wards, you hereby waive any and all present and future claims you may have against The Motivational Edge and its staff, funded service providers, employees, agents, affiliates and board members.

Student First Name	Student Middle Name
Student Last Name	Gender
Date of Birth	Allergies
Please list allergies:	What program are you interested in?

School ID #	Student ID
Current Grade	Current School
Student Mobile Phone	Student Email

Street	City
State	Zip Code
(If not, we may be able to help you find affordable coverage – call 211 or visit www.thechildrenstrust.org/parents/health-connect/insurance.)

Parent/Guardian First Name	Parent/Guardian Last Name
Parent/Guardian Email	Parent/Guardian Phone
Is this a cell/mobile phone? YesNo	Parent/Guardian Address

Case Management Agency	Case Manager Name
Case Manager Email	Case Manager Office Number
Case Manager Mobile Phone

Please confirm which Adverse Childhood Experiences the child has experienced (if any): Emotional AbuseEmotional NeglectPhysical AbusePhysical NeglectSexual AbuseSubstance Abuse	Desired Outcomes
Type of Services Requested (1:1, Group, etc):	Location of Services to be Rendered:
Frequency/Duration Authorized:

Guardian Ad Litem Name	Guardian Ad Litem Email
Guardian Ad Litem Mobile Phone

Therapist Name (leave blank if not applicable)	Therapist Email (leave blank if not applicable)
Therapist Mobile Phone (leave blank if not applicable)