Adolescent Leadership Council (TALC) Hasbro Children's Hospital Breadcrumb Lifespan HomeLifespan Centers & ServicesAdolescent Leadership Council (TALC) The Adolescent Leadership Council Patient Intake Form Copy URL to Clipboard URL COPIED! Print The Adolescent Leadership Council Patient Intake Form Date Adolescent Information Adolescent's Name First Middle Last Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Adolescent's Age Date of Birth Grade in School (if during summer, please give upcoming school year) Teen Cell Phone Number Teen Email Adolescent T-Shirt Size Parent Information Parent 1 Name First Middle Last Parent 2 Name First Middle Last Home Phone Number Parent Cell Phone Number Parent Email Best way to contact you Parent T-Shirt Size Doctor Information Primary MD Name Title Title - None -MissMsMrMrsDrOther… Enter other… First Middle Last Specialist Name Title Title - None -MissMsMrMrsDrOther… Enter other… First Middle Last Specialty Referred By Name Title Title - None -MissMsMrMrsDrOther… Enter other… First Middle Last Additional Information Diagnosis Food Allergies (For anyone who may attend meetings) Notes Leave this field blank Please review and fill out this form if you are interested in joining TALC The program coordinator will get back to you. General Consent Forms: The Adolescent Leadership Council (TALC) General Consent Form The Adolescent Leadership Council (TALC) General Consent Form - Spanish The Adolescent Leadership Council (TALC) General Consent Form - Portuguese Adolescent Leadership Council (TALC) Parent Council Patient Intake Form Programs and Events