Elevate Bridgeport

Student Registration for 2025-2026 School Year

Student's First and Last Name

Student's Phone Number

Student's Personal Email

Student's School Email

Student's Home Address

Student's Primary Language

Student's Date of Birth

Month

Day

Year

What High Schol will you be attending in 2025-2026?

Bassick High School

Bridge Academy High School

What grade will you be entering?

Please list all known allergies. If none, write N/A

Parent/Guardian First & Last Name

Parent/Guardian's Phone Number

Parent/Guardian's Email

Emergency Contact Full Name

Emergency Contact Phone

I give permission for my child to attend any offsite trips with the Elevate Bridgeport Staff during mentoring sessions throughout the 2025-2026 school year. I authorize Elevate Bridgeport to provide transportation as needed by either Elevate Van or Teacher/Mentor vehicle.

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 its publications and social media.

I understand that in order for my child to participate in any off site mentoring activities, a liability waiver must be completed.

Liability Waiver - English

Liability Waiver - Spanish