Elevate Bridgeport

Saturday Academy Respite Program

Starting Saturday, February 21st

from 9am to 1pm

Child's First Name

Child's Last Name

Home Address

Child's Birthday

Month

Day

Year

Parent or Guardian Full Name

Parent or Guardian Phone

Parent or Guardian Email

Emergency Contact Phone

Emergency Contact Full Name

does this child have any allergies or medical condition we should be aware of? Write N/A if not applicable.

What age group is your child in?

Group 1 - ages 6 to 8

Group 2 - ages 9 to 12

Group 3 - ages 13 to 17

I give permission for my child to participate in Elevate Bridgeport's Saturday Academy Respite Program at the Elevate Offices, 180 Boston Avenue, Bridgeport, CT.

I give permission for my child to participate in any off-site adventure activities during the Saturday Academy Respite Program.

I hereby grant Elevate Bridgeport permission to use the above child's likeness in a photograph, video, or other digital media in any and all it's publications or social media.

Flyer - Saturday Academy Respite Program.png