2025 Building Bridges HBCU Program

2025 Building Bridges HBCU Program
Thursday, October 16, 2025
Cost includes Bus Trip to the Building Bridges HBCU College Fair in Boston, HBCU TShirt, and dinner in Boston at Fire & Ice!

Students are selected on a first come basis. Application and payment must be submitted together tosecure their spot on the trip. Applications and payment can be hand delivered to MLKFS 106 Wilbraham Road Springfield, MA 01109

Applications can also be submitted via email to pbernard@mlkjrfs.org. Electronic applications must be submitted with asame dayelectronic payment such as Cash App $MLKFSor credit card.For Cash App payments, please include your student’s name in “For” when submitting payment.For credit card payments, call (413) 746-3655.
2025 Building Bridges HBCU Program
Bus Trip Application
Student Information:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Shirt Size*
Home Phone*
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Email*
example@example.com
Academic Information:
School*
Anticipated Graduation Year*
Current GPA*
Parent/Guardian Information*
Relationship to Child*
Cell*
CellHomeWork:
Alternate Telephone
Format: (000) 000-0000.
E-Mail*
example@example.com
Did you attend the MLK College Tour?*
If yes, what year?*
Emergency Contacts other than Parent/Guardian listed above: Emergency contacts are also authorized to pick up child unless otherwise noted.
Contact 1 Name*
Telephone Number*
Format: (000) 000-0000.
Relationship to child*
YesNo
Contact 2 Name
Telephone Number
Format: (000) 000-0000.
Relationship to child
YesNo
Please answer the following statements by checking the yes or no boxes:
No ☐Yes If yes, please describe:Please answer the following statements by checking the yes or no boxes:
My child has allergies that the program needs to be ☐No ☐Yes If yes, please describe: aware of. Example: Peanut Allergy, Bees, etcHealth and Medical Information and Consent Form
No ☐Yes If yes, please describe*
needs to be aware of. (Example: Asthma, etc
Consent for Medical Care*
I,*
Give ☐ Do Not Give, permission forConsent for Medical Care:
chaperones of the Martin Luther King, Jr. Family Services, Inc. (MLKFS) that are trained in first aid to give my child first aid when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize Chaperones of the MLKFS to transport my child to the nearest medical care facility and to secure necessary medical treatment for my child while on the trip to HBCU Fair.

Please authorize each statement by checking the boxes.
I authorize staff to administer emergency and/or scheduled medication to my child as scheduled/needed inI authorize staff to transport/have my child transported to the nearest medical/emergency facility as
HEALTH INSURANCE INFORMATION
NAME OF PARENT/GUARDIAN INSURED #1*
HEALTH INSURANCE CARRIER*
POLICY #*
NAME OF PARENT/GUARDIAN INSURED #2
HEALTH INSURANCE CARRIER
POLICY #
HEALTH INSURANCE CARD
Please attach a copy of the front and back of your health insurance card to the end of the application. Students will not be allowed to attend the trip without health insurance information.
MEDIA RELEASE PERMISSION FORM*
My child has permission to appear in media coverage, fundraising, and event photo sessionsMy child does not have permission to appear in media coverage, fundraising, and event photo
sessions which have been authorized by Martin Luther King Jr. Family Services, Inc. (MLKFS) during the HBCU fair trip and related events.
SIGNATURE DATE*

Clear
SIGNATURE DATE

MonthDayYear
Date
RELEASE OF LIABILITY
In consideration of my participation in any Martin Luther King Jr. Family Services, Inc. activities including the Historical Black Colleges and Universities fair and its/their related events and activities
I,*
, the undersigned, acknowledge, appreciate and

agree that PARENT / GUARDIAN FIRST AND LAST NAME

1. The risk of injury from the activities involved in this program does exist, and while skills, equipment, and personal discipline may reduce this risk, the risk of injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately, and, 4. I, for myself and on behalf of my heirs, assign personal representatives and next of kin. HEREBY RELEASE INDEMNITY, AND HOLD HARMLESS THE MARTIN LUTHER KING JR. FAMILY SERVICES, INC. their officers, officials, agents, and / or employees, other participants, sponsoring agencies, sponsors, advertisers, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

This is to certify that I as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releases’, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnity and hold harmless the Releases’ from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.
PARENT/GUARDIAN SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Should be Empty:

2025 Building Bridges HBCU Program

Thursday, October 16, 2025

2025 Building Bridges HBCU Program

Bus Trip Application

Student Information:

Academic Information:

HEALTH INSURANCE INFORMATION

HEALTH INSURANCE CARD

RELEASE OF LIABILITY