Form 4: 2026-2027 Emergency and Medical Release Form
This form must be completed by at least one parent (preferably both) and submitted to the Bridge Tutorial Ministries(BTM) Leadership Team.  Although we desire to keep this information confidential, a copy of this completed form will be accessible to the Leadership Team each time the students meet for BTM classes and medical concerns will be shared with your student’s tutors as deemed necessary. In case of an emergency, the Leadership Team may need to use the help of the facility staff, BTM Tutors, Designated Parent, and Emergency Medical Personnel. The Leadership Team may see fit to share this form at that time. It is imperative that we have all the information essential to caring for your student in the event that it becomes necessary.
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Email *
Family Last Name *
Student 1 First and Last Name *
Student 1 Date of Birth (month, day, year) *
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Student 2 First and Last Name
Student 2 Date of Birth (month, day, year)
MM
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DD
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YYYY
Student 3  First and Last Name
Student 3 Date of Birth (month, day, year)
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/
DD
/
YYYY
Student 4 First and Last Name
Student 4 Date of Birth (month, day, year)
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/
DD
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YYYY
Address, City, State, and Zip Code *
Parent/Legal Guardian 1 First and Last Name *
Best Contact Number *
Parent/Legal Guardian 2 First and Last Name
Best Contact Number
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