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Resurgence Lab Registration
Marking Period 1
Email
*
Student Name
*
First
Last
Student Grade
*
Choose
6th
7th
8th
9th
10th
11th
12th
Lab Offerings
*
Select the lab(s) you would like to register for:
S.T.E.M. LAB - Mondays, 2:30-4:30 pm
BIBLE LAB - Tuesdays, 2:30-4:30 pm
ART LAB - Wednesdays, 2:30-4:30 pm
PHYSICAL ACTIVITY LAB - Thursdays, 2:30-4:30 pm
MENTORING - Fridays, 2:30-4:30 pm
What school do you attend?
*
Your answer
How did you hear abou Resurgence?
Your answer
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
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New Hampshire
New Jersey
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent/Guardian Name
*
First
Last
Phone
*
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
Consent
*
Transportation from school, to labs, and drop-off at home is provided by Bridge Street Ministries and available for all registered Resurgence students. Students will be dropped off at the address listed above unless otherwise instructed by a parent or legal guardian. By checking this box, you are authorizing Bridge Street Ministries (BSM) to provide transportation for the student listed above during the duration of this lab. This form grants Bridge Street Ministries permission to use my/our child's photos in any of their promotional advertisements.
I am a parent or legal guardian of the student listed above, and hereby consent to the terms listed on this form.
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