Bridge To Freedom School Enrollment Form Summer: June 15th-July 17th, 2026

(Please complete one form for each child. Accepting scholars currently in grades K-8.)

PROGRAM HOURS: Monday - Friday; 8:30am - 2:30pm. (No after care hours are available)

INSTRUCTIONS: Please complete one form for each child enrolled in the Bridge To Freedom School program.

If requested information is non-applicable, mark N/A. If requested information is unavailable or unknown at this time, mark U/A.

ENROLLMENT FEE. The enrollment fee is a one-time fee of $100 and is non-refundable.
SPACES ARE LIMITED. After your application is reviewed, you will be contacted by the Program Director and if space is available, payment will be due immediately via Pushpay, Check or Cash.

Today’s Date (MM/DD/YEAR):

Parent/Guardian's Information

Last Name:

First Name:

Middle Name:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

This address will receive a confirmation email

Home Address:

Relationship to Child:

Father Mother Legal Guardian Foster Parent Grandparent Other

Does this child currently live with you?

Yes No

If no, what is the child's home address?

Child’s Demographic Information

Child's Last Name:

Child's First Name:

Child's Middle Name:

Child's Preferred Name or Nickname:

Child’s Date of Birth (MM/DD/YEAR):

Child’s Gender:

Male Female

What is your child’s primary/native language (language spoken at home)?

Child’s Race/Ethnicity (Check One Only):

African American/Black, non-Latino Native American/Indian or Alaska Native Asian American Native Hawaiian or Pacific Islander Latino/Hispanic European American/White, non-Latino Mixed Heritage Other

Does this child have a sibling(s) who currently participates, or has participated in the Bridge To Freedom School program?

Yes No

What other academic enrichment or extra-curricular activities does your child participate in during the summer or academic school year (e.g. organized sports, music or dance lessons, academic tutoring, clubs, etc.)?

What are your child’s hobbies or interests?

What type of school does your child attend?

Public Charter School Faith-Based Private Home School Other

What is the name and location of the school your child attends during the academic school year?

Name:

City:

State:

What grade did your child recently complete this school year? (school year 2025-2026)

K 1 2 3 4 5 6 7

Has your child been in foster care at any point in his or her life?

Yes No

Child’s Academic Information

Does your child participate in any of the following educational programs (check all that apply)?

Bilingual Education ESL/LEP Special Education Gifted and Talented 504B Plan Other None

Has a doctor, health professional, teacher, or school official ever informed you that your child has a learning disability or social-emotional (behavioral) disability? *

Yes No

If yes, please explain:

Does your child have an Individualized Education Program (IEP) on file?

Yes No

Has your child ever repeated a grade?

Yes No Unknown

Has your child attended the Bridge to Freedom Summer Program before?

Yes No

What is your child’s reading proficiency level?

Above Grade Level At Grade Level Below Grade Level Non-applicable Unknown

Child’s Medical Information

Does your child have health insurance?

Yes No

If yes, please provide the information requested below: Health Insurance Carrier:

Please explain any special procedures that should followed in the event that your child has a medical emergency: *

Could your scholar benefit from Behavorial Health Services?

Yes No I would like to know more information about this.

Any developmental delay or physical impairment (please describe below)

Does your child currently need or use medication prescribed by a doctor?

Yes No

If yes, please be sure all medication(s) is dispensed daily before attending camp.

If there is anything else that you would like to share about your child, please indicate here (ie. List allergic reactions….)

Bridge To Freedom School Enrollment Form Summer: June 15th-July 17th, 2026

Description

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