Future Builders Registration Form

BRIDGES Future Builders Registration Form

Future Builders is a year-round program that provides experiential, hands-on learning for a diverse group of middle school youth to become leaders in building a better future for themselves and their community.

As you complete this form, you will see that there are sections for you and your parents/guardians to complete. It will be your responsibility, as the applicant, to insure that these sections are completed. Do not leave any portions of this application incomplete.

Before you complete this form, please read the BRIDGES Programs Liability Waiver, the Code of Conduct, and the Tennessee Wildlife Federation (Great Outdoors University-BRIDGES programming partner) Liability Waiver.

As you complete this form, online payment is required (for the $15 registration fee). Please note that your registration form will only be processed if you submit this $15 payment at the time of your registration form submission. If this is a problem for you, please call BRIDGES at 901-452-5600.

First Name
Last Name
Email Address
Phone Number (Format: 999-999-9999)

Street Address
City
State
Zip Code
Date of Birth
School
2010-2011 Grade
School District
If Other, please specify
Ethnic Affiliation
If Other, please specify
Shirt Size
Gender
How did you hear about Future Builders?
In 50 words or less, tell why you want to be a Future Builder:
What is your favorite thing to do outdoors?
What do you think it means to be a leader?
What is one instance in which you stood up as a leader?
Parent/Guardian Information:
Mother/Guardian Name
Mother/Guardian Employer
Mother/Guardian Position
Mother/Guardian E-Mail Address
Mother/Guardian Work Phone
Mother/Guardian Home/Cell Phone
Mother/Guardian Home Address
Mother/Guardian City, State, Zip
Father/Guardian Name
Father/Guardian Employer
Father/Guardian Position
Father/Guardian E-mail Address
Father/Guardian Work Phone
Father/Guardian Home/Cell Phone
Father/Guardian Home Address
Father/Guardian City, State, Zip
Health Information:
In order to take proper care of the participants and manage safety most effectively, it is crucial
to have accurate, up to date information on our participant's health. This information WILL be kept
private and will only be used in case of an emergency. Please completely fill out this form,
so that all information can be entered into our system accurately.
In case of an emergency, please notify:
Full Name
Relationship to you:
Contact's Home Phone
Contact's Cell Phone
Please list any medications being taken regularly. 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 the above
information is true, that I have read and agreed to
the BRIDGES Programs Liability Waiver, and that I
have read and agreed to the Code of Conduct.
.
Parent Signature:
By typing my name below, I verify that I agree to
the TN Wildlife Federation-Great Outdoors University and the and the BRIDGES Liability Waivers.

BRIDGES Future Builders Registration Form

Basic Participant Information:

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