Bridges for Kids Intake Form

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Bridges for Kids is program for youth ages 5-12 years of age. They can either be matched with a one on one mentor or in a group mentoring group. There are also monthly programs for the whole family or for assistances with Christmas, Thanksgiving, school supplies, etc..

This is a basic Intake form to enroll a child. A follow up form will be mailed out to you after you fill this form out.

Caregiver Name *

Please list all Children that are eligible for Bridges for Kids

Street Address *

City/Town/Zip *

Phone Number *

Email address *

Relationship to Youth Enrolled *

Mother

Father

Grandparent

Other:

Occupation

Emergency Contact- Name and Number *

What are you looking for in the program?

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