Camp Fall Break #1 2025

Student Name

First NameLast Name
Gender*
Age*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School*
Grade*
Hearing Status*
I will stay with my child during activity;
Parent or Guardian's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Day Phone

Area CodePhone Number
Night Phone

Area CodePhone Number
Work Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Email*
example@example.com
Emergency Contact*

First NameLast Name
Day Phone

Area CodePhone Number
Night Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Alternate Emergency Contact

First NameLast Name
Relationship to camper:
Day Phone

Area CodePhone Number
Night Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number

Persons Permitted to Pick Up Camper other than Parent|Guardian
Name

First NameLast Name
Relationship
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Name

First NameLast Name
Relationship
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Any additional information we should know?

Releases & Consents
Media Release

I give my permission for Bridges to allow photographs or interview statements of my child to be used as part of any publicity coverage that may occur including newsletters, public relations materials, or coverage by area media in regard to BridgesDHH programming.
yesno
Please Sign & Date*

Clear

We ask that you complete a form for each child, but please list the name(s) of other campers here for reference:
Should be Empty: