Building Bridges - Fall 2025
September 9 - October 28 | Tuesdays from 6:30-7:30 pm
Attendee's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Attendee's Gender
*
male
female
other
Attendee's Grade in Fall of 2025
*
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Attendee's School
*
Attended Building Bridges Previously?
yes
no
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Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian relationship
*
parent
legal guardian
other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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Information on Individual Who Passed Away
Name of Person Who Passed Away
*
Attendee's Relationship to Person Who Passed Away
*
Nature of Their Death
*
How long ago did they pass away?
*
Provide details about any diagnoses, behavioral concerns, or special considerations for your child.
*
Medical & Emergency Information
Please list any medical issues or allergies:
Family Physician
Family Physician Phone Number
Please enter a valid phone number.
Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
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Child Release Form
Contract of Confidentiality - I submit this contract of confidentiality to show that I have the responsibility of maintaining the confidentiality of all children and their families during Children’s Programs. It is expected that during the Children’s Program event, personal information will be discussed. In order to make this comfortable for everyone, it is our policy to ask Children’s Program participants to honor confidentiality as well. It is imperative that whatever is discussed at our Children’s Program not be repeated to anyone. The signature of a parent or guardian indicates that you have explained the above policies to your child(ren) and will assist them in maintaining confidentiality. I understand that Children’s Program facilitators, and/or volunteers cannot keep confidentiality if there is knowledge of intent to harm self or others.
I give permission to Hospice of Wichita Falls to provide emergency treatment to my child. In the event that appropriate treatment cannot be provided at the program site, I consent for my child to be taken to emergency department where the physician will exercise his/her best judgment as to the diagnosis and treatment. I further consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered. I understand that should the need for medical care arise, I will be financially responsible for all costs incurred in rendering or providing medical attention to my child and Hospice of Wichita Falls is not obligated to provide payment for services rendered.
*
yes
no
I give Hospice of Wichita Falls staff permission to photograph, video and/or interview me or my child and to use these images, recordings and/or quotes in training staff and in promoting the Children’s Program to the community via social media, brochures, ads and newspaper articles and other means of publication.
*
yes
no
Submit
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