Bridge Information Form
Due to the nature of Bridge programs, we require that you complete a Bridge Information Form and have a family meeting with a Bridge staff person prior to attending any programs. As we are unable to take walk-ins, if you would like to speak to a Bridge staff member or set up a tour, please contact us -- we would love to connect to get to know you and answer any questions you have!

The Bridge Information Form allows us to get to know your child better, determine placement, and develop a support plan. The information is kept confidential and will take about 15 minutes to complete.
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CHILD/STUDENT'S NAME (FIRST AND LAST) *
GENDER *
DATE OF BIRTH *
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GRADE (IF APPLICABLE) *
HOME ADDRESS (STREET, CITY, STATE, ZIP)* *
CHILD/STUDENT LIVES WITH *
IF OTHER:
CELL PHONE *
HOME PHONE
PRIMARY CAREGIVER'S NAME *
RELATIONSHIP TO CHILD/STUDENT *
IF OTHER
CELL PHONE *
ADDRESS (IF DIFFERENT FROM ABOVE)
EMAIL *
PREFERRED METHOD OF CONTACT *
SECONDARY CAREGIVER'S NAME
RELATIONSHIP TO CHILD/STUDENT
Clear selection
IF OTHER
ADDRESS (IF DIFFERENT FROM ABOVE)
CELL PHONE
HOME PHONE
EMAIL
PREFERRED METHOD OF CONTACT
WHICH CAMPUS WILL YOU BE ATTENDING? *
Required
WHICH PROGRAMS ARE YOU INTERESTED IN? *
Required
EMERGENCY CONTACT (OTHER THAN PARENTS) *
RELATIONSHIP TO CHILD/STUDENT *
PHONE *
SIBLINGS LIVING AT HOME
CHILD #1 (NAME & DATE OF BIRTH)
CHILD #2 (NAME & DATE OF BIRTH)
LIST OTHER CHILDREN HERE
WITH WHAT DISABILITIES HAS YOUR CHILD/STUDENT BEEN DIAGNOSED? *
Required
IF OTHER PLEASE DESCRIBE:
EDUCATION | EMPLOYMENT
SCHOOLING *
Required
SCHOOL NAME (IF APPLICABLE)
RECEIVES SPECIAL EDUCATION IN SCHOOL? *
Required
RECEIVES 1:1 SUPPORT *
Required
INCLUDED IN TYPICAL, AGE-APPROPRIATE CLASSROOM *
Required
CLASSES THAT CHILD/STUDENT IS INCLUDED IN (IF APPLICABLE)
SELF CONTAINED CLASSROOM
IF OTHER
EMPLOYED?
EMPLOYER (IF APPLICABLE)
PARTICIPATES IN SPECIALIZED WORK PROGRAM
RECEIVES ADDITIONAL THERAPY / SUPPORT SERVICES? *
Required
TYPE OF THERAPY SUPPORT (IF APPLICABLE)
COMMUNICATION / COGNITION (CHECK ALL THAT APPLY) *
Required
MOBILITY (CHECK ALL THAT APPLY) *
Required
CAN EAT SNACK PROVIDED? *
Required
LIST SPECIAL DIETARY NEEDS (I.E. PUREED, GLUTEN-FREE, ETC.)  *
EATS BY MOUTH *
Required
USES SPECIAL UTENSILS OR CUP *
Required
REQUIRES SUPERVISION WHILE EATING
LIST ALL FOOD AND OTHER ALLERGIES. IF NONE, INDICATE N/A. *
HAS YOUR CHILD/STUDENT EXPERIENCED SEIZURES? *
HYGIENE *
Required
IF NON-VERBAL, LIST SIGNS OR GESTURES THAT MAY INDICATE THEIR NEED TO USE THE BATHROOM:
SOCIAL BEHAVIOR | INTERESTS | PREFERENCES
MY CHILD/STUDENT IS (CHECK ALL THAT APPLY)  *
Required
ACTIVITIES YOUR CHILD/STUDENT ENJOYS AND / OR PARTICIPATES IN: *
MY CHILD/STUDENT BECOMES UPSET WHEN OR DOES NOT ENJOY: *
WHAT BEHAVIORAL TENDENCIES DOES YOUR CHILD/STUDENT HAVE?  (CHECK ALL THAT APPLY)  *
Required
IF OTHER:
WHAT RESPONSES ARE MOST EFFECTIVE FOR YOUR CHILD/STUDENT ONCE A BEHAVIOR HAS OCCURRED? *
MY CHILD/STUDENT IS BEST COMFORTED BY: *
WHAT PROACTIVE STRATEGIES ARE HELPFUL IN PREVENTING THESE BEHAVIORS?  (CHECK ALL THAT APPLY) *
Required
IF OTHER:
LIST ANY SENSORY ACTIVITIES THAT MAY BE PROACTIVE IN HELPING PREVENT THESE BEHAVIORS: *
FOR WHAT SITUATIONS DO YOU WISH TO BE CONTACTED? *
WHAT HOPES / DREAMS DO YOU HAVE FOR YOUR CHILD/STUDENT ATTENDING OUR PROGRAM? (FAITH-BASED, SOCIAL, BEHAVIORAL, ETC.) *
IS CALVARY YOUR HOME CHURCH? *
Required
IF NO, WHAT CHURCH DO YOU ATTEND IF YOU ATTEND ONE?
HOW DID YOU HEAR ABOUT BRIDGE DISABILITY MINISTRIES? *
CONSENT, RELEASE, & MEDICAL AUTHORIZATION / RELEASE OF LIABILITY FORM
Recognizing the risk associated with the operation of a ministry for individuals with a disability and the possibility of physical injury or loss, the below named parent/s of the above-named individual hereby agree to the following during the duration of his/her participation in the program.
CONSENT, RELEASE, & MEDICAL AUTHORIZATION
1. Blanket Permission: I hereby grant permission for full participation in any or all of the activities/programs that are held on or off-site with the Bridge Ministries of Calvary Church, Souderton, PA (the “Church”) during the period commencing with the date of this form.
2. Release: I understand that the Church staff and adult supervisors will endeavor to provide individual care and safety for each participant in each activity and/or program. I am aware that neither the Church nor any member of its staff or adult supervisors can assume responsibility for any injury or damage, which may occur in connection with such program or activity. Therefore, by signing below I am agreeing to the Legal Release of Liability and the Indemnification of the Church, which are set forth on this form and incorporated herein by reference, by which I am releasing and/or holding harmless the Church, its staff, and volunteers from any liability incurred by the Church arising out of any Church-sponsored activity in which he/she participates.
3. Medical: I also give my consent, approval, and authorization for Church staff or other adult supervisors to authorize emergency medical treatment if reasonably deemed necessary by them.
LEGAL RELEASE OF LIABILITY & INDEMNIFICATION
The Parent hereby:
a. Agrees to review all the information provided by the Church concerning any Church sponsored activity, and agrees to the precautions planned for the safety and care of the participants;
b. Acknowledges that, notwithstanding the exercise of reasonable safety precautions, participation in any Church sponsored activity involves certain actual and potential risks(s) of loss;
c. Agrees that should the participant be asked to return home due to disciplinary action, medical reasons, or otherwise, it shall be the Parent’s responsibility to provide transportation home and to cover all associated and related expenses;
d. Releases the Church from all liability for any loss incurred by the participant or by the Parent arising out of or related to any Church sponsored activity, except for loss due to the Church’s willful misconduct, and
e. Agrees to indemnify and hold the Church harmless from any liability for loss incurred by the Church (1) as the result of injuries to the participant or (2) due to the acts of the participant, occurring in the context of any Church related activity.

As used herein, the term “Loss” means personal injury, sickness, loss of life, or damage to or loss of property, real or personal; “Church” means Calvary Church, Souderton, PA, its Elders, Trustees, Deacons, Pastors, and staff, its leadership supervisors, volunteers, and members; and “Parent” means the parent(s) or legal guardian(s) of the participant identified above.

Parent represents, warrants, and agrees that by signing this form the Parent has full legal authority to do so; that the Parent has legal custody of the participant; that the approval and agreement of any other parent or guardians has been obtained by Parent, and that the undertakings herein shall be binding upon the Parent, any other Parent or guardian, the participant, and their respective heirs, personal representatives, and assigns.
1)  As of this date, I affirm that the information given on this form is true and accurate, and I hereby also grant my assent to the Consent, Release, & Medical Authorization/Release of Liability form. * *
2)  I give permission for my child/student to be photographed. The picture may be used in any form of positive publicity. *
PARENT/LEGAL GUARDIAN'S NAME *
DATE: *
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