metct

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
Student Info








School Info






Student Address




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






Demographics







Additional Information








Interest and Behavior
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


Agency Referral Additional Information





Services Requested





Guardian Ad Litem



Therapist



Approved Pick Up
Please enter the name, relationship to the youth, and the phone number 
for anyone approved to pick up your child:



Authorization for Photography/Video
I, 
, the parent or guardian of 
hereby authorize and give consent to the staff of The Motivational Edge and/or its funded service providers as follows:

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.