The Bridge Academy Emergency Contact Form 2020-2021
Please fill out this form and let us know if any of the information changes during the school year.  Thank you!
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Preferred Language of Communication   *
Current Grade *
Student's Full Name (John P. Mask) *
Gender *
Student Date of Birth *
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Student Cell Phone
Student Email:
Student Current Address *
Student Lives with *
CONTACT INFORMATION
It is vital that our office has access to telephone numbers where you can be contacted in case of illness or an emergency.  Please notify us immediately of ANY CHANGES during the school year.

Name/s of primary caregiver/s *
Primary Caregiver Address: Number, Street, (Apt/Fl), City, Zip *
Home Phone:
Work Phone. Include the name and number of all primary caregivers (for example, Bill Smith: 100-300-20000 and Sarah Smith 102-400-3000): *
Cell Phone.  Include the numbers of all primary caregivers.  Include the name and number of all primary caregivers (for example, Bill Smith: 100-300-20000 and Sarah Smith 102-400-3000). *
Email. We communicate primarily through email so this section is very important!  Include the name and email addresses of all primary caregivers (for example, Bill Smith: bsmith@ccr.org and Sarah Smith: ssmith2@xmail.com): *
NON-CUSTODIAL PARENT?
Are there any legal restrictions on the release of your child or his/her records to a non-custodial parent? Please answer below; If  you choose yes, please provide legal documentation to the school administration.
Non Custodial Parent *
If you answered yes to the previous question, please give the name of the person to whom we SHOULD NOT send your child's records:
EMERGENCY CONTACTS
By listing your emergency contacts below you are giving permission to contact these people in the event your child's primary caregivers are unable to be reached. These contacts are given permission by the caregivers to be given information in the event of an emergency and have permission to retrieve the student from school.
Emergency Contact 1: First Name, Last Name, Relationship to Student, Cell Phone (for example: Sally Smith, Grandmother, 200-388-4000): *
Emergency Contact 2: First Name, Last Name, Relationship to Student, Cell Phone
Emergency Contact 3: First Name, Last Name, Relationship to Student, Cell Phone
Emergency Contact 4: First Name, Last Name, Relationship to Student, Cell Phone
Medical Information
In case of accident or illness, and if I can't be reached, I hereby authorize the school to call the primary health care provider listed below and to follow his/her instructions. If is not possible to reach the health care provider, the school has my authorization to make any necessary arrangements.
Primary Care Physician's Name: *
Doctor's Phone Number *
Hospital Preference: *
Please describe any Medical Problems/Allergies that your child has that we should know about:
Please check the applicable boxes below:
The Bridge Academy works closely with several statewide Charter School Advocacy Programs.  Their main goal is to create more Charter Schools in the state of Connecticut.  As part of that effort, we would like to share your name and contact information EXCLUSIVELY with them. *
The Bridge Academy and the State of Connecticut's Husky Plan work together to make sure that our students receive good health care.  If your child does not have health insurance, or if you are interested in receiving low-cost or free health care for your child, please let us know by checking the appropriate box below: *
Read the Bridge Academy Student Handbook here: https://bridgeacademy.org/student-handbook-20-21/.  Check below to indicate that both you and your child have read the Handbook and the included asbestos notice and that you are familiar with our expectations and policies: *
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