After School Program Intake

After School Program Intake: Bridge Leadership Academy
Welcome to The Torch for the School Year 2026-2027!

Every Tuesday and Thursday from 4 to 6pm we hold space for tutoring and enrichment activities.

Kindly complete this form to assist us in providing the best possible support for your family.
How many students would you like to add to this form?
Student #1 Information
Student #1 Name

First NameMiddle NameLast Name
Student #1 Preferred Name
Student #1 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student #1 Pronouns
Student #1 T-shirt Size
Student #1 School Name
Please type full name of school
Student #1 School Email
example@example.com
Student #1 Grade
Does Student #1 Have an Individualized Education Plan?
Student #2 Information
Student #2 Name

First NameMiddle NameLast Name
Student #2 Preferred Name
Student #2 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student #2 Pronouns
Student #2 T-shirt Size
Student #2 School Name
Please type full name of school
Student #2 School Email
example@example.com
Student #2 Grade
Does Student #2 Have an Individualized Education Plan?
Student #3 Information
Student #3 Name

First NameMiddle NameLast Name
Student #3 Preferred Name
Student #3 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student #3 Pronouns
Student #3 T-shirt Size
Student #3 School Name
Please type full name of school
Student #3 School Email
example@example.com
Student #3 Grade
Does Student #3 Have an Individualized Education Plan?
Parent/Household Information
Parent/Guardian Name

First NameLast Name
Parent's Preferred Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status
Primary Language

Other
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.Format: (000) 000-0000.
2nd Parent Primary Language

Other
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Housing Status
Household Type
Total Number of Children
Medical & Safety Information
Please list any accommodations or special needs your student(s) may need in order to participate.
If none, type "none"
Please list any known health conditions that your student(s) has. This will ensure that we are prepared for any and all emergencies related to your student(s).
For example: asthma, epilepsy, diabetes, etc.
Please list any medications that your student(s) currently takes.
If none, type "none"
Please list any known allergies your student(s) has.
If none, type "none"
Please list the preferred hospital for your student(s) 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(s) regarding their medical or safety needs?
If none, type "none"
Relationship to student(s)?
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Acknowledgements
Is your family interested in social/emotional support?
Do you give us permission to take pictures of your student for the sake of our website and social media?
I understand that if my student is unable to attend a scheduled session, I am responsible for notifying Bridge Leadership Academy at least 24 hours in advance whenever possible. I understand that timely notification helps BLA plan appropriately for meals, staffing, and program activities.
I understand that my student's involvement in this program is determined by their behavior and academic performance. The Bridge Leadership Academy can choose to remove any student from the program if they do not meet academic and behavioral standards.
I understand that my student must be transported to and from the Bridge building on time and prepared for the session. Drop off is 4:00-4:15pm and pick up is 5:45-6:00pm.
I understand that in the case of a medical or safety emergency, the Bridge Leadership Academy policy is to call 911 and the emergency contact provided for the student.
Parent Signature
Should be Empty:

After School Program Intake: Bridge Leadership Academy

Welcome to The Torch for the School Year 2026-2027!

Student #1 Information

Student #2 Information

Student #3 Information

Parent/Household Information

Medical & Safety Information

Acknowledgements