After School Program Intake

After School Program Intake: Bridge Leadership Academy
Welcome to BLA's After School Program for 2025-2026!

Every Tuesday and Thursday from 4 to 6pm we hold space for tutoring and Esports. Our website will list all the meeting times and when we won't be holding session (for Holidays, weather or District PD days).

Our address is 10521 Blue Ridge Blvd. Kansas City, MO 64134

Please drop off your student no later than 4:15pm.

Please pick up your student no later than 6pm.
Basic Information
Student Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone*
Please enter a valid phone number.
EnglishSpanishOther
Would you like to add another parent/guardian to this form?*
2nd Parent/Guardian Name*

First NameLast Name
2nd Parent/Guardian Email*
example@example.com
2nd Parent/Guardian Phone*
Please enter a valid phone number.
EnglishSpanishOther
EnglishSpanishOther
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Date of Birth*

MonthDayYear
Date
What shirt size does your student wear?*
Please specific if it is a Youth or Adult size.
Academic Information
What grade is your student in?*
What school does your child attend?*
Student School Email (optional)
example@example.com
A's and B'sB's and C'sC's and D'sD's or lowerOther
YesNo
If yes, please describe the IEP and your student's needs.
MathEnglish/Comm ArtsScienceHistory/Social StudiesComputer ScienceForeign LanguageArtOther
YesNo
Very oftenOftenSometimesRarelyAlmost Never
Very oftenOftenSometimesRarelyAlmost Never
Medical & Safety Information
Please list any accommodations or special needs your student may need in order to participate. *
Please list any known health conditions that your student has. This will ensure that we are prepared for any and all emergencies related to your student. *
For example: asthma, epilepsy, diabetes, etc.
Please list any medications that your student currently takes.*
Please list any known allergies your student has. *
Please list the preferred hospital for your student in the case of an emergency.*
If you don't have a preferred hospital, just type "Any".
Is there anything else we need to know about your student regarding their medical or safety needs?
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Acknowledgements
Why do you want your student to be a part of this program?*
Yes, I'd like to hear more about thisNo, thank you
Yes, I give permission.No, I do not give permission.
I understand
I understand
I understand
I understand
I understand
Parent Signature*

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After School Program Intake: Bridge Leadership Academy

Welcome to BLA's After School Program for 2025-2026!

Basic Information

Academic Information

Medical & Safety Information

Acknowledgements