Immersion Registration – Bridge Street Ministries

Bridge Street Ministries

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Grand Rapids Immersion Individual Registration

Step 1 of 3

33%

Please select which trip you are registering for*
Church or Organization Name:*
Church or Organization Name:*

General Information
Group Leader's Email*

We need this so that we can notify them that you've filled out your form!
Your Name*
First Last
Nickname:
Gender:
Today's Date
MM
DD
YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Birth Date*
MM
DD
YYYY
What grade are you going into this fall?*
I am 18 or older*
- Yes
- Nope
Background Check Information
Please note that any adults working with or around children, youth, or adults with developmental disabilities are required to provide all of the following information, and consent to relevant background checks prior to their start date. All information provided in this application is secure and used solely by BSM staff for administrative purposes. Under no circumstance will the information provided be shared with an outside party.
Race:*
- American Indian or Alaskan Native
- Asian or Pacific Islander
- Black
- Hispanic
- White
- Other/Unknown
Drivers License Number or State ID:*
State of Issuance:*
Have you ever been convicted of a crime?*
- Yes
- No
If yes, please explain:*
Have you ever been asked to step away from a staff or volunteer role working with children, youth, or adults with developmental disabilities?*
- Yes
- No
If yes, please explain*
Social Security Number*
Clear Picture of Driver's License or State ID*
- I hereby authorize the BSM to obtain information pertaining to any charges and/or convictions I may have had for violation of municipal, county, state or federal laws. This information will include but not be limited to that obtained via police records, the National Sex Offender’s Registry, and the DHS Central Registry.
Emergency Contact
Please provide contact information for the person we should call in case of an emergency.
Name*
First Last
Your relationship to this person:*
Your relationship to this person:*
- Father
- Mother
- Step Parent
- Guardian
- Other
Please specify*
Phone*
Secondary phone
Email*
Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Father Name*
First Last
Father Phone*
Father Email*
Mother Name*
First Last
Mother Phone*
Mother Email*
Step Parent Name*
First Last
Step Parent Phone*
Step Parent Email*
Guardian Name*
First Last
Guardian Phone*
Guardian Email*
Person to Notify*

Medical Information
All information provided will be held in confidentiality.
Health Insurance Company*
Name of Policy Holder*
Policy Number*
Group Number*
Doctor's Name
Phone*
Hospital Preference
Date of Last Tetanus Shot*
MM
DD
YYYY
Please list any physical limitations that might hinder participation in activities (allergies, asthma, migraines, etc.)
Medications
Please list medications and doses that are taken regularly.
List
Medication Dosage Specific times taken each day Reason for taking
Allergies
Medication, Food, and Other Allergies Describe reaction and explain how it is managed

List all known
Release Form
Immersion Participant is:*
Minor Student (under 18)
*
- I hereby certify that I am the parent or legal guardian of the above named participant and I give my permission for him/her to take part in any of the activities sponsored by the Bridge Street Ministries (BSM). I am aware that there may be risks and dangers which I will assume personal responsibility for and will release and agree to indemnify and hold harmless expenses or damages of any kind growing out of or related to any activities or transportation to and from activities. My signature below authorizes the BSM to photograph my child for use in BSM publications and/or future promotional materials.
Adult student or leader (Must be over 18)
*
- I hereby certify that to the best of my knowledge I am in a state of health sufficient for me to take part in any of the activities sponsored by BSM without jeopardizing my well-being. I am aware that when taking part in activities like this there may be risks and dangers which I will assume personal responsibility for and will release and agree to indemnify and hold harmless to BSM, its officers and directors, employees, and any parties volunteering on behalf of BSM, from all actions, costs, expenses or damages of any kind growing out of or related to any activities or transportation to and from the activities. My signature below authorizes the BSM to take my photograph for use in BSM publications and/or future promotional materials.
Signature of Parent, Guardian or Participant
Date
MM
DD
YYYY

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