Bridge Builders intake form template

Parental Waiver and Consent form
Authorization and Acknowledgment:By signing thiswaiver and consent,I ,
the legal parent/guardian grant permission for myself/my children to participate in any activities including but not limited to weekend community events, and enrichment groups. I recognize and acknowledge the inherent risks that these activities may present for me/my children. I acknowledge that the possession or use of alcoholic beverages and illegal drugs are strictly forbidden. I understand the possession of any weapon (firearm, knife, explosives, etc is strictly prohibited. Because I acknowledge the risks of attending myself or allowing my children to participate, I agree to release and hold harmless the volunteers of Bridge Builders to the New Generation, directors, officers, and affiliates from any and all injury claims of any other nature which may result from my/my children’s participation at and travel to or from activities. In order to effectively monitor progress, Change the Narrative Project requests parental/guardian consent through a waiver to access: Student ID, First & Last name, Date of Birth, Gender, Ethnicity, English language, Disability status, Parent Educational level, Academic Testing Records, Transcript Info, and Discipline data.
Medical Consent:I give my permission for Bridge Buildersto the New Generation members and volunteers to provide and arrange for any necessary medical treatment to myself/my children while under their care, offsite emergency care.I accept responsibility forthe costs of all such medical treatment.

I acceptI decline medical care for my child and/or family.
Photography Release:I grant permission to BridgeBuilders to the New Generation members, volunteers, and affiliates to utilize my appearance, performance, or voice in any manner and media throughout the world for promotion, reporting, or publication. Additionally, Bridge Builder to the New Generation members, volunteers, and affiliates may use my child/my children’s name, likeness, voice, and biographical material in connection with the publication, promotion, exhibition and distribution of such material. I understand that no royalty, fee, or any other compensation of any kind shall become payable to me because of such release and use of any photograph.

I acceptI decline photography release for my child and/ or family.
Please contact Bridge Builders to the New Generation CEO Shamawn Wright should you have any questions.

Email:Bridgebuildersng@gmai.com(925) 436-6250

I have read this form carefully and have had all questions answered before signing this legal document and giving the consents and waivers contained in it. I acknowledge that this is a legal document, and my agreement will bind me to its terms.
Print Name
Date

MonthDayYear
Date
Signature:
Date

MonthDayYear
Date
BridgeBuilderstotheNewGenerationPre-CollegeReadiness
First Name
Middle Name
Last Name
School
ID
Grade Level
What is your gender orientation?

MaleFemaleLGBQT+ Lesbian, Gay, Bisexual, Queer, Transgender, etc.Non- conformingI’d rather not say
Racial/ ethnicity groups

WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Pacific IslanderHispanic/ LatinoOther
What is your grade point average (GPA)?

0.0- 1.01.0 - 2.02.0 - 3.03.0 - 4.04.0+
What best describes your family dynamics?

Single-Parent HouseholdTwo-Parent HouseholdBlended FamilyFoster Care
What is the highest degree or level of school your parents have completed? If currently enrolled, the highest degree received

No schooling completedNursery school to 8th gradeSome high school, no diplomaHigh school graduate, diploma or the equivalent (for example: GED)Some college credit, no degreeTrade/technical/vocational trainingAssociate degreeBachelor’s degreeMaster's DegreeProfessional DegreeDoctorate DegreeOther
Child's Name
Birthdate

MonthDayYear
Date
Parent/Guardian
Home/work Number
Cell Phone
E-mail Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts (when attempts to reach parents are not successful)
Name #1
Home Number
Work Number
Cell Phone
Name#2
Home Number
Work Number
Cell Phone
Child’s Medical Care
Hospital to take child in case of an emergency
Child’s Health Insurance
Name of Insurance Plan
Certificate Number (or ID) #
Policy Holder’s Name
Special Conditions, Disabilities, Allergies, or Medical Information for Emergency Situations
BridgeBuilderstotheNewGenerationPre-CollegeReadiness
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