Bridge Information Form

Your name *

Email address *

First and last name of Bridge applicant *

Gender *

Male

Female

Grade (if applicable)

Address *

Bridge applicant lives with *

Both parents

Mother

Father

Other

Primary caregiver's name *

Relationship to Bridge applicant *

Mother

Father

Other

Phone number *

Preferred method of contact *

Understanding that most Bridge communications will come via email and require regular checking, what secondary form of contact do you prefer?

Mobile

Text

Address (if different from Bridge applicant)

Secondary caregiver's name *

Relationship to Bridge Participant *

Mother

Father

Other

Preferred method of contact *

Understanding that most Bridge communications will come via email and require regular checking, what secondary form of contact do you prefer?

Mobile

Text

Address (if different from Bridge applicant)

EMERGENCY CONTACT INFORMATION

Name of emergency contact (other than primary or secondary caregiver listed above) *

Relationship of emergency contact to Bridge participant *

Best phone number for emergency contact *

Household members

Please let us know information about OTHER people in your household, EXCLUDING primary/secondary caregivers listed above.

Which campus will you be attending? *

Check ONLY the ONE where participant will regularly attend.

Quakertown

Souderton

Name of 1:1 support person (if applicable)

Which Bridge programs are you interested in? *

Check all that apply (Reference website for program descriptions)

Adult Enrichment

Inclusion

Respite

Sunday Morning

Wednesday Nights

With what disabilities has your child / student been diagnosed? *

Check all that apply

ADD / ADHD

Autism

Cerebral palsy

Developmental delay

Down syndrome

Emotional disability

Hearing impaired

Intellectual disability

Learning disability

Post-traumatic stress disorder

Seizure disorder

Sensory processing disorder

Speech / language disorder

Visual impairment

Other

EDUCATION | EMPLOYMENT

Schooling *

Attends school

Home school

Does not attend school

Name of school (if applicable)

Is the applicant in a self-contained classroom? *

Check all that apply

Not applicable

Learning support

Emotional support

Autistic support

Life skills

Other

Does the applicant receive special education in school? *

Yes

Not applicable

Does the applicant receive 1:1 support in school? *

Yes

Not applicable

Is the applicant included in typical, age-appropriate classrooms? *

All day

Part of the day

Not applicable

In what classes is the applicant included (if applicable)?

Is the applicant employed?

Yes

Name of employer (if applicable)

If the applicant participates in a specialized work program, please describe.

Does the applicant receive additional therapy / support services? *

Yes

Not applicable

COMMUNICATION | COGNITION | MOBILITY | DIETARY

Communication / Cognition *

Check all that apply

Verbal

Non-verbal / Non-speaking

Follows simple, one-step directions

Follows two-step directions

Uses sign language / gestures

Uses assistive technology (picture boards, communication device, etc.)

Wears hearing aids

Mobility *

Check all that apply

Walks independently

Uses a wheelchair

Use braces or orthotics

Falls on occasion

Can the applicant eat snack provided? *

Yes

List special dietary needs (i.e. pureed, gluten-free, etc.) or none if not applicable. *

Do any of the following apply to the applicant? *

Check all that apply

Eats by mouth

Uses special utensils or cup

Requires supervision while eating

Other

List all allergies (food or others) *

If no allergies, enter N/A.

Has the applicant experienced seizures? *

Yes

What hygiene needs does your child / student have? *

Check all that apply

Uses bathroom independently

Uses bathroom with supervision

Needs transfer assistance

Follows a schedule

Needs prompts / reminders to use bathroom

Wears a diaper - parent / caregiver will be called for assistance

Has feminine needs - parent / caregiver will be called for assistance

If the applicant is non-verbal, what signs or gestures may indicate the need to use the bathroom?

SOCIAL BEHAVIOR | INTERESTS | PREFERENCES

The applicant is *

Check all that apply

Shy

Outgoing

Prefers to be alone

Initiates interactions on his / her own

Needs support in connecting with others

Likes being the center of attention

Prefers not to be recognized publicly

Adapts to new situations well

Adapts to new situations with difficulty

Other

Activities the applicant enjoys and participates in: *

My child / student becomes upset / does not enjoy *

What behavioral tendencies does the applicant have? *

Check all that apply

Wandering / elopement

Yelling

Biting

Hitting

Pushing

Throwing

Difficulty following directions

Sometimes destructive

Aversion to touch

Repetitive talking / gestures / actions

None of these

Other

What responses are most effective for the applicant once a behavior has occurred? *

How is the applicant best comforted? *

What proactive strategies are helpful in preventing these behaviors? *

Check all that apply

Verbal feedback for appropriate behavior

Frequent breaks (short walk, drink, etc.)

Physical gestures ("high 5," pat on the back, handshake, etc.)

Choice of preferred activities following appropriate behavior

Redirection

Sensory activities

Previewing activities

Picture / written schedules

Fidget toys / transitional objects / mainipulatives

Support during transitions

Periodic individual attention from caregivers

Fewer demands

Decrease in sensory input (noise, talking, visual stimulation)

Limitations on tools (i.e. no scissors, sharp pencils, glue, etc.)

None of these

Other

List any sensory activities that may be proactive in helping prevent these behaviors. *

For what situations do you wish to be contacted? *

What hopes / dreams do you have for the applicant in attending Bridge programs? (Faith-based, social, behavioral, etc.) *

Is Calvary your home church? *

Yes

Other

How did you hear about Bridge Disability Ministries? *

CONSENT, RELEASE, & MEDICAL AUTHORIZATION / RELEASE OF LIABILITY FORM

Recognizing the risk associated with the operation of a ministry for individuals with a disability and the possibility of physical injury or loss, the below named parent/s of the above-named individual hereby agree to the following during the duration of his/her participation in the program.

CONSENT, RELEASE, & MEDICAL AUTHORIZATION

1. Blanket Permission: I hereby grant permission for full participation in any or all of the activities/programs that are held on or off-site with the Bridge Ministries of Calvary Church, Souderton, PA (the “Church”) during the period commencing with the date of this form.
2. Release: I understand that the Church staff and adult supervisors will endeavor to provide individual care and safety for each participant in each activity and/or program. I am aware that neither the Church nor any member of its staff or adult supervisors can assume responsibility for any injury or damage, which may occur in connection with such program or activity. Therefore, by signing below I am agreeing to the Legal Release of Liability and the Indemnification of the Church, which are set forth on this form and incorporated herein by reference, by which I am releasing and/or holding harmless the Church, its staff, and volunteers from any liability incurred by the Church arising out of any Church-sponsored activity in which he/she participates.
3. Medical: I also give my consent, approval, and authorization for Church staff or other adult supervisors to authorize emergency medical treatment if reasonably deemed necessary by them.

LEGAL RELEASE OF LIABILITY & INDEMNIFICATION

The Parent hereby:
a. Agrees to review all the information provided by the Church concerning any Church sponsored activity, and agrees to the precautions planned for the safety and care of the participants;
b. Acknowledges that, notwithstanding the exercise of reasonable safety precautions, participation in any Church sponsored activity involves certain actual and potential risks(s) of loss;
c. Agrees that should the participant be asked to return home due to disciplinary action, medical reasons, or otherwise, it shall be the Parent’s responsibility to provide transportation home and to cover all associated and related expenses;
d. Releases the Church from all liability for any loss incurred by the participant or by the Parent arising out of or related to any Church sponsored activity, except for loss due to the Church’s willful misconduct, and
e. Agrees to indemnify and hold the Church harmless from any liability for loss incurred by the Church (1) as the result of injuries to the participant or (2) due to the acts of the participant, occurring in the context of any Church related activity.

As used herein, the term “Loss” means personal injury, sickness, loss of life, or damage to or loss of property, real or personal; “Church” means Calvary Church, Souderton, PA, its Elders, Trustees, Deacons, Pastors, and staff, its leadership supervisors, volunteers, and members; and “Parent” means the parent(s) or legal guardian(s) of the participant identified above.

Parent represents, warrants, and agrees that by signing this form the Parent has full legal authority to do so; that the Parent has legal custody of the participant; that the approval and agreement of any other parent or guardians has been obtained by Parent, and that the undertakings herein shall be binding upon the Parent, any other Parent or guardian, the participant, and their respective heirs, personal representatives, and assigns.

Affirmation of Information / Consent, Release & Medical Authorization / Release of Liability *

As of this date, I affirm that the information given on this form is true and accurate, and I hereby also grant my assent to the Consent, Release, & Medical Authorization / Release of Liability form.

Permission for the applicant to be photographed *

I give my permission for my child / student to be photographed. The picture may be used in any form of positive publicity.

Parent / Legal Guardian's Name *

PROFILE

EMERGENCY CONTACT INFORMATION

EDUCATION | EMPLOYMENT

COMMUNICATION | COGNITION | MOBILITY | DIETARY

HYGIENE

SOCIAL BEHAVIOR | INTERESTS | PREFERENCES

CONSENT, RELEASE, & MEDICAL AUTHORIZATION / RELEASE OF LIABILITY FORM

CONSENT, RELEASE, & MEDICAL AUTHORIZATION

LEGAL RELEASE OF LIABILITY & INDEMNIFICATION