Student Name *

First Name

Last Name

Student Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Phone

(###)

###

####

Birthdate *

MM

DD

YYYY

Do you attend a church?

Yes

No

Parent/Guardian 1 Name *

First Name

Last Name

Parent/Guardian 1 Phone *

Country

(###)

###

####

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

Country

(###)

###

####

Parent/Guardian 2 Address

*Only fill out if different from Child's, or Guardian 1

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First Name

Last Name

Emergency Contact Number

(###)

###

####

Medical Treatment Permission *

I authorize The Bridge to provide medical treatment up to and including care by a medical professional or hospital.

Yes

No

Media Permission *

I grant permission for use of parent or child statements, image, or voice, related to The Bridge and/or associated programming on film, photograph, social media, website, or any form of print.

Yes

No

Communications Permission *

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

Yes

No

Transportation Permission *

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

Yes

No

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. This agreement is in place until/unless an updated agreement is signed.

First Name

Last Name

Date *

MM

DD

YYYY