New Student Enrollment – Bridge Street Ministries

Resurgence New Student Registration

Student Name*
First Last
Grade*
Date of Birth*
MM
DD
YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Legal Guardian Name*
First Last
Parent/Legal Guardian Phone*
Parent/Legal Guardian Email*
Preferred Method of Contact
- Phone
- Email
- Text
Emergency Contact*
First Last
Emergency Contact Phone*
Additional information about student (specific areas of need, health concerns, food allergies, etc.):
Does this student require transportation to and from Resurgence (1056 Bridge St NW)?*
- Yes
- No
Consent*
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 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 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 activities. My signature below authorizes Resurgence staff and volunteers to access this student’s grades via ParentVUE in order to help them develop personalized education goals. I authorize the BSM to photograph my child for use in BSM publications and/or future promotional materials. I authorize the BSM to provide transportation to and from events sponsored by BSM.

Resurgence is an after-school program developed specifically for students at Westwood Middle School by focusing on academic, social, spiritual and community development. Resurgence is a program of Bridge Street Ministries (BSM), a Christ-centered non-profit ministry in West Grand Rapids. Contact us at bsmgr.org | info@bsmgr.org