Student Inquiry Form — Boston's Bridge To Excellence

Please fill out all information below

Program

Student's Name

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Gender

Male

Female

When will student attend program?

Programs Available At: Maurice J. Tobin School: 7:30AM - 9:30AM (Before School) 4:10PM - 6:00PM (After School) 7:30AM - 6:00PM (Full Day, Vacation Week, Summer Programming) Ellis Elementary School: 7:00AM - 9:30AM (Before School) 4:10PM - 6:00PM (After School) Chittick Elementary School: 7:00AM - 8:30AM (Before School) 3:10PM - 6:30AM (After School) 7:30AM -6:30PM (Full Day, Vacation Week, Summer) Edison K-8 School: 7:00AM - 8:30AM (Before School) 3:10PM - 6:30AM (After School) 7:30AM -6:30PM (Full Day, Vacation Week, Summer) New School Starting Summer 2019 Up Academy Holland Monday - Friday (except Wed.) 3:30 PM - 6:00 PM Wednesday 12:30 - 6:30 PM New Schools Starting Fall 2019 Guild Elementary School 7:00AM - 8:30AM (Before School) 3:10PM - 6:30AM (After School) 7:30AM -6:30PM (Full Day, Vacation Week, Summer) We also offer 5-day, 3-day and 2-day schedule options.

Which days will student attend program?

Monday

Tuesday

Wednesday

Thursday

Friday

Home Room Number

Phone Number

Forms of Payment

Parent or Guardian Name

First Name

Last Name

Primary Phone Number

Email Address

Address 1

Town/City

State

Place of Work

Emergency Contact 1

First Name

Last Name

Emergency Contact 1 Primary Phone Number

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Emergency Contact 1 Secondary Phone Number

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Emergency Contact 2

First Name

Last Name

Emergency Contact 2 Primary Phone Number

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Emergency Contact 2 Secondary Phone Number

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Is there anyone else who is authorized to pick up your child from the program?

First Name

Last Name

Authorized Pick Up Contact Phone Number

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Doctor's Name

First Name

Last Name

Doctor's Phone Number

Dentist's Name

First Name

Last Name

Dentist's Phone Number

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Preferred Hospital

Insurance/Health Coverage

Insurance Policy Number

Any known medical issues, medications, or medicine or food related allergies