Apply for a Program

BH Hybrid Mentoring Program Application

APPLY BELOW!

Registration Fee

* Indicates required field

Current Grade: *

School District: *

Household Information

Primary Guardian Name: *

Contact Number: *

E-Mail: *

Child Name: *

Contact Number (if applicable): *

Email (if applicable): *

Are there legal court order relating to the child's custody or release? *

Emergency Contact/Authorized Pick-Up (in addition to names listed above)

Name 1: (First, Last Name) *

Relationship to Child: *

Contact Number: *

Name 2: (First, Last Name) *

Relationship to Child: *

Contact Number: *

Name 3: (First, Last Name) *

Relationship to Child: *

Permission to Use Photographs

I hereby give Bernadette’s House, and its employees or agents, permission to take, copyright, use and publish photographs of or concerning me (and/or my children or wards, if under the age of 18) for the purpose of business of Bernadette’s House, including without limitation, the preparation of promotional materials for Bernadette’s House, including materials prepared for the purpose of fundraising.

Health History Application and Waiver of Liability

In order to ensure confidentiality and safety of your child's information, post your online application, you will receive an e-mail with a Health History Form that must be completed by State Law. You will also provide a separate Signature for a Waiver of Liability as well as Permission to Use Photograph.

These documents can be e-mailed to [email protected] or sent via mail to:

Bernadette’s House, Inc.
14625 Baltimore Ave, Suite 171
Laurel, MD 20707-4902.

NOTE: This Online Form, Medical History Documents as well as Payment confirmation confirm that your Application is complete and your child is ready to start.

Mark Yes or No to Photograph usage. *

Submit

Program Registration

Program Fees