immersion online release form – Bridge Street Ministries

Please select which trip you are registering for*

Church or Organization Name:*

Group Leader's Email

Please type your group leader's email address here so they get a heads up that you registered.

General Information

Your Name*

First Last

Nickname:

Gender:

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone

Birth Date

What grade are you going into this fall?

Are you 18 or older?*

Yes

No

Select "Yes" if you will turn 18 before Immersion ends.

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

This field is hidden when viewing the form

Clear Picture of Driver's License or State ID*

Max. file size: 256 MB.

Certification

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:*

Please specify*

Phone*

Secondary phone

Email

Emergency Contact Address

Emergency Contact Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Information

This information is required in case of an emergency. All information provided will be held in confidentiality.

Health Insurance Company

Name of Policy Holder

Policy Number

Group Number

Doctor's Name

Doctor's Phone Number

Hospital Preference

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

Waiver

for minors (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.

Parent Signature

Waiver

for adult students or leader (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

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice