Registration for SY 2024-2025 | Elevate Bridgeport

Student Registration for 2024 - 2025 School Year

Student's First Name

Student's Last Name

Student's Email

Street Address

City

Postal / Zip code

Student's Phone Number

Parent / Guardian First Name

Parent / Guardian Last Name

Parent / Guardian Email

Parent / Guardian Phone Number

Emergency Contact Name - Other than Parent/Guardian

Parent / Guardian Work Phone Number

Emergency Contact Phone Number

Student Date of Birth

Any known allergies - list all

I give permission for my child to go on off site trips with the Elevate Bridgeport Staff during mentoring sessions throughout the year.

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

Thanks for submitting!