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 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. 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. This agreement is in place until the beginning of the following program year.

First Name

Last Name

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 staff for program purposes.

Yes

No

Transportation Permission *

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

Yes

No

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

First Name

Last Name

Date *

MM

DD

YYYY