Yearly Registration Form

Home Information
What is the student's home address?*

Street Address

Unit #

CityState

Zip Code
How many adults live at home?*
How many children under 18 live at home?*
Total Household Size
The following question asks about your family's monthly gross income. Your answer to this question does not determine eligibility to participate in Bridge the Gap programming. This information is used internally for data and funding purposes only.
What is your estimated monthly gross income amount?*
What is your estimated annual income?*
Parent or Caretaker Name*

First NameLast Name
Parent or Caretaker Email*
example@example.com
Parent or Caretaker Phone*
Please enter a valid phone number.
Caretaker Type*
Do you want to add a second parent or caretaker's information?*

YesNo
Parent or Caretaker Name

First NameLast Name
Parent or Caretaker Email
example@example.com
Parent or Caretaker Phone
Please enter a valid phone number.
Caretaker Type
Emergency Contact Information

This is someone who has permission to pick up the student and will be called if caretaker(s) aren't available in case of emergency.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
What is the relationship of this person to the student?*
Do you want to add information about a second emergency contact?*

YesNo
Second Emergency Contact Name

First NameLast Name
Second Emergency Contact Phone
Please enter a valid phone number.
What is the relationship of this person to the student?

Medical Release

In the event of an emergency, accident or illness, it is imperative that the parent, or a person designated by the parent, be available to care for the student and arrange necessary medical care. In the event that the parent, guardian, or emergency contact is not available, the sick or injured student will be transported by ambulance, at parent’s expense, to the nearest hospital within the school district.
I (Parent/Guardian) have read the above information and understand the Emergency Information above. (Please write in your name below.)
Medical Insurance Carrier
I/We realize this is a voluntary program, and that by participating I/we accept the following terms and conditions. I/we understand that SMCSD assumes no responsibility or liability for injuries/illnesses of my/our child. I/we further understand that I/we release and hold the SMCSD, their officers, agents, employees, and volunteers (“Releasees”) harmless from any and all liability, known and unknown, or claims which may arise out of my/our child’s participation in the Expanded Learning Program. I/we further acknowledge and agree that my/our child’s participation in the Extended Day Program includes my/our child’s possible exposure to an illness from an infectious disease including, but not limited to, MRSR, influenza and COVID 19; and I/we freely assume such risks and hold free and harmless Releasees from any and all illness, disability, death, loss or damage to person or property arising there from, to the fullest extent permitted by applicable law. (Please type your name below to acknowledge you have read and agree to the above information.)

Pickup & Release Information
As parent or guardian, by completing this page I understand that the After School Program will begin immediately after school is out and will end by 6:00pm.

Students will not be released to go home from the After School Program until they are signed out by the parent or guardian, emergency contact, or if a completed walk home form has been submitted.
Check the options that the student is allowed to use to get home:*

Student will ride the bus home from afterschool programStudent will walk home from afterschool programStudent will be picked up from afterschool

Photo Release Form
By submitting this form, you confirm that you have carefully read and understand the Photo Release Agreement and agree to each of the terms and acknowledgments in the linked waiver.

This authorization will remain in effect while your student is enrolled at Bridge the Gap College Prep or until you have provided Bridge the Gap College Prep with written notice of withdrawal of consent to this agreement.
Please indicate if you give permission for your student or any family members to appear in videos, photos or audio recordings without compensation (e.g., as part of brochures, slide shows or program websites).*

Yes, I give permissionNo, I do not give permission

Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Yearly Registration Form

Student information

Home Information

Emergency Contact Information

Medical Information

Medical Release

Pickup & Release Information

Photo Release Form