B.R.I.D.G.E. to Success Student Enrollment Form
Thank you for taking the time to complete this form. It is very important to us to build healthy relationships with all of our participants. Your responses allow us to learn more about you as an individual participant and your family unit.
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Student Name *
Student date of birth *
Parent/guardian name *
Parent/guardian age *
Residence zip code *
Student email
Parent/guardian email *
Phone Number *
Which school do you attend? *
Grade Level *
Gender *
What is your race or ethnicity? *
How tall is your student? *
How much does your student weigh? *
Do you have any siblings in your household that go to other Metro Nashville Public Schools (Kindergarten – 12th grade)? *
How many siblings do you have? *
Does your parent/guardian work? *
Have you been to the doctor in the past 6 months? *
Have you been to the dentist in the past 6 months? *
Do you eat a healthy meal at least once a day? (For example: meals that include fresh fruits and/or vegetables?) *
How much exercise do you typically get per week? *
Who referred you to the program?  If not an individual, what organization? *
Thank you for completing this intake form. Please enter date of completion *
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