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.Format: (000) 000-0000.
Parent 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
Student Primary Language

Other
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
Over the past 2 school years, what type of grades did your student receive?

Other
Does your student have an IEP (Individualized Education Program)?
If yes, please describe the IEP and your student's needs.
Which subjects does your student need help with? Choose all that apply.

Other
Does your student have reliable internet access at home?
How often does your student work on homework at home? Take-home assignments, iReady, EdPuzzle, etc.
How often do you check your student's grades?
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.Format: (000) 000-0000.
Acknowledgements
Why do you want your student to be a part of this program?
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?
Prior to each session, BLA will reach out to each parent and get a headcount for the evening. This ensures enough food is prepared for each student who attends. I understand it is my responsibility to promptly respond to all emails and/or text messages about whether or not my student will attend each session.
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 dinner will be provided from 4-4:30. Any student arriving past 4:30 may not receive a meal.
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 BLA's After School Program for 2025-2026!

Basic Information

Academic Information

Medical & Safety Information

Acknowledgements