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Bridge Builders seeks to develop among high school students a group of future leaders who can lay aside
individual & cultural differences & work for the benefit of all.

Bridge Builders^® Application

Thank you for deciding to apply to Bridge Builders^®, a two-year leadership and diversity program for outstanding high school students. As you complete the application, you will notice that there are pages for various people other than yourself to complete. It is your responsibility to ensure these sections are completed.

There are items on this application that do not factor into the selection process. However, this application is used as the master source of information for the Bridge Builders^® program.

Please note the following:

A week long, residential Junior Leadership Conference is a must for all participants. Session assignments and additional information will be given at a mandatory parent meeting. This meeting must be attended in order for a student to participate in Bridge Builders^®.

Do not leave any portions of this application blank. Also, please read the BRIDGES Programs Liability Waiver before filling out this form.

Student Information:

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programs

Our programs cover 3 broad areas

workforce development, training and youth

experiential learning

o2e

events

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up-to-date event info

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477 North Fifth St. Memphis, TN 38105
(p) 901-452.5600 | (f) 901-320.1004
info@bridgesusa.org

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Title
First Name:
Full Middle Name
Last Name:
Surrname:
Home Address
Street Type:
City:
If other, please specify:
State:
Zip Code (5 digits only):
Home Phone Number (999) 999-9999:
Cell Phone Number (999) 999-9999:
Email Address:
Date of Birth mm/dd/yyyy:
Gender:
School:
If other, please specify:
Which group do you most identify with? Check all that apply. This is for statistical purposes.	African American/Black Caucasian American/White Hispanic/Latino Asian/Pacific Islander Native American/American Indian Choose not to report
If other, please specify:
T-Shirt Size:
Please select your Annual Household Income Range.
Please select your religious affiliation:
If other, please specify:
Church/Congregation:
Picture Upload
Tentative Conference Dates:
The conference week is pre-selected. Please select the session(s) that you cannot attend:
Session One (June 7-12)
Session Two (June 14-19)
Session Three (June 21-26)
In 150 words or less, explain why you want to be a Bridge Builder:
List any of the following that you wish to be considered:
Awards/Honors:
Community Service Projects:
Clubs/Sports (include offices held):
Has any member(s) of your family been a member of Bridge Builders?
If yes, list name(s) and class:
Check the other BRIDGES programs you participated with:	Future Builders BRIDGES PeaceJam BRIDGES Experiential Learning Center
Parent/Guardian Information:
Prefix
Father/Guardian First Name
Father/Guardian Last Name
Father/Guardian Home Address
Father/Guardian Street Type:
Father/Guardian City:
Father/Guardian State:
Father/Guardian ZIP Code (5 digits only):
Father/Guardian Home Phone Number (999) 999-9999:
Father/Guardian Cell Phone Number (999) 999-9999:
Father/Guardian Employer
Father/Guardian Position
Father/Guardian Work Phone Number (999) 999-9999:
Father/Guardian Email Address
Mother/Guardian Prefix
Mother/Guardian First Name
Mother/Guardian Last Name
Mother/Guardian Home Address
Mother/Guardian Street Type:
Mother/Guardian City:
Mother/Guardian State:
Mother/Guardian ZIP Code (5 digits only):
Mother/Guardian Home Phone Number (999) 999-9999:
Mother/Guardian Cell Phone Number (999) 999-9999:
Mother/Guardian Employer
Mother/Guardian Position
Mother/Guardian Work Phone Number (999) 999-9999
Mother/Guardian Email Address
Health Information
In case of emergency, please notify:
Emergency Contact Full Name:
Relationship to Student:
Emergency Contact Home Phone Number (999) 999-9999 :
Emergency Contact Cell Phone Number (999) 999-9999 :
Please list any medications that you are currently taking. (This information will remain private):
Please check any of the following medical conditions that you may have:	- No Medical Conditions Asthma Heart Conditions Diabetes Pregnancy Back/Neck Injuries Allergies to bee stings Recently broken bones Hypoglycemia Seizures Dizziness/Vertigo Other
If you checked any of the above, please briefly explain:
Do you have any dietary restrictions? (Vegetarian meals/kosher foods/etc.)
Student Signature:
By typing my name, I verify that all of the about information is true, and that I agree to the
BRIDGES Programs Liability Waiver:
Parent/Guardian Signature
By typing my name, I verify that all of the above information is true, and that I agree to the
BRIDGES Programs Liability Waiver