Student Name *

First Name

Last Name

Student Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Phone Number

(###)

###

####

Birthdate

MM

DD

YYYY

Do you attend a church?

Yes

No

Parent/Guardian 1 Name

First Name

Last Name

Parent/Guardian 1 Phone Number

(###)

###

####

Parent/Guardian 1 Address

*Only fill out if different from child's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian 2 Phone Number

(###)

###

####

Parent/Guardian 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

Please complete this section if additional contact information beyond parent/guardian information would be helpful.

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Student Agreement *

By checking this box, I agree to the expectations and permission listed above. This agreement is in place until the beginning of the following program year.

Parent Agreement *

By checking this box, I agree to the expectations and permission listed above. This agreement is in place until the beginning of the following program year.

Medical Treatment Permission *

In case of an emergency, I provide permission for The Bridge to have my child treated by a physician and/or hospital.

Yes

No

Media Permission *

I grant my permission for the rights to use and record my child's image and/or voice on film, photograph, print, and other media to be used on social media, website, and or any other form of print.

Yes

No

Communications Permission *

I provide permission for my child to receive texts from The Bridge.

Yes

No

Transportation Permission *

I provide permission for a representative of The Bridge to transport students for program and/or emergency purposes.

Yes

No

Student Electronic Signature *

By typing my name below, I am providing an electronic signature that acknowledges that I have read and understand all of the expectations and permissions listed in this form. I acknowledge that this agreement is in place until the beginning of the following program year.

First Name

Last Name

Parent/Guardian Electronic Signature *

By typing my name below, I am providing an electronic signature that acknowledges that I have read and understand all of the expectations and permissions listed in this form and have provided all information as completely as I can. I acknowledge that this agreement is in place until the beginning of the following program year.

First Name

Last Name

Date *

MM

DD

YYYY