Bridge Program Application

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Student's Name:

First Name:

Last Name:

MI:

Preferred first name/nickname for nametag:

Gender:
FemaleMale

T-shirt size:
SMLXLXXL

Other:

Home Address:

City:

State:

Zip:

Email Address:

Student Cell Phone:

High School you recently graduated from:

Tribal Affiliation(s):

Mother/Guardian's Name:

Tribal Affiliation(s):

Home Phone:

Cell:

Work:

Father/Guardian's Name:

Tribal Affiliation(s):

Home Phone:

Cell:

Work:

Emergency Contact if parent/guardian is unable to be reached:

Name:

Telephone:

Relationship to student:

Participant Agreement

I understand that this application will reserve my spot for the Fall 2013 American Indian Bridge Program. I understand that, as a participant, I am expected to be in attendance for the entire program the week before classes begin, on the Black Hills State University campus in Spearfish, South Dakota. I also give BHSU permission to use my name and/or photos in which I may appear for future marketing or promotional materials.

I Agree

Electronic Student Signature:

Date: