Sign Up Form
Vision: To bridge the youth to opportunities that inspire long-term success and happiness.

Please complete the Google Form on behalf of your child who will be a part of Bridges by Liberation. Through the Bridges program children will go on trips outside of Washington county in order to align with our purpose.

Purpose: Expose the youth to opportunities that extend beyond their local community, through the use of field trips, mentorship, education, enrichment activities, etc. in order to foster well-rounded, successful youth and adults.

Please contact Fred Chavis or Bria Chavis should there be any changes that need to be made to this form. It is important that all information remains updated.
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First Name *
Last Name *
Birthdate *
MM
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DD
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YYYY
Gender *
Does your child have any form of medical, physical, emotional, or behavioral conditions? If yes, please specify. *
Is your child currently undergoing any form of medical or psychological treatment, including medication? If yes, please specify. *
Does your camper have any allergies? If yes, please specify. *
Parent/Guardian Name #1 (First, Last) *
Mailing Address *
Best Contact Number *
Email Address
Parent/Guardian Name #2 (First, Last)
Mailing Address
Best Contact Number
Email Address
Emergency Contact Name (Please use an adult who is NOT the parents/guardians, in the event that the parents/guardians cannot be reached) *
Emergency Contact Relationship to Child *
Emergency Contact Phone Number *
Please briefly share your child's likes and dislikes.
Shirt Size *
Photo Release Statement: Bridges by Liberation may use images in print publications, online publications, presentations, websites, and social media. *
I ___________________________, understand all the information in this form. All information provided is accurate. I understand that the failure to provide accurate information may lead to termination of services at the co-owners discretion. I understand that this is a service that has the campers and staffers safety as the number one concern. I understand that it is my responsibility as the parent/guardian to reach out to the co-owners if there is a change that needs to be made on the campers file. The failure to make adjustments to the file, on my behalf as the parent/guardian puts my child at risk, therefore liability is strictly on the parent/guardian. Please write full name below to confirm agreement. *
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