Sand Dollar Club Registration Please enable JavaScript in your browser to complete this form.School Name *Not ListedA.C. Corcoran ElementaryAcademic Magnet High SchoolAllegro Charter in North CharlestonAshley River Creative ArtsBaptist Hill Middle & High SchoolBelle Hall ElementaryBlessed Sacrament Catholic SchoolBuist AcademyC.E. Williams Middle School North CampusC.E. Williams Middle School South CampusCamp Road Middle SchoolCarolina Voyager Charter SchoolCarolina Park ElementaryCharles Pinckney ElementaryCharleston Charter School for Math and ScienceChicora Elementary SchoolDeer Park Middle SchoolDrayton HallE. B. Ellington ElementaryEast Cooper Montessori Charter SchoolEdith L Frierson Elementary SchoolHarbor View Elementary SchoolHaut Gap Middle SchoolJames B. EdwardsJames Island ElementaryJennie Moore Elementary SchoolJerry Zucker Middle SchoolJulian Mitchell Elementary SchoolKnightsville Elementary SchoolLadson ElementaryLambs Elementary SchoolMamie P. Whitesides ElementaryMary Ford Early Learning and Family CenterMeeting Street @ BrentwoodMeeting Street AcademyMilitary Magnet AcademyMinnie Hughes ElementaryMorningside Middle SchoolMoultrie Middle SchoolMount Holly Elementary SchoolMount Pleasant AcademyMurray-LaSaine Montessori SchoolNewington Elementary SchoolNorth Charleston Creative Arts ElementaryNorth Charleston Elementary SchoolNorthwoods Middle SchoolOakbrook Elementary SchoolOrange Grove Charter SchoolPepperhill Elementary SchoolR.B. Stall High SchoolSanders ClydeSimmons-Pinckney MiddleSpringfield ElementarySt. Andrews School of Math and Science St. James-Santee Elementary SchoolSt. John's High SchoolStiles Point Elementary SchoolSummerville CatholicThe Charleston Catholic SchoolW.B. Goodwin ElementaryWilliam Reeves ElementaryWindsor Hill Arts Infused ElementaryCaregiver Name (Parent or Guardian)FirstLastYour Relationship to Student(Mother, Father, Grandparent Ect.)Caregiver PhoneCaregiver EmailStudent 1 NameFirstLastStudent 1 GenderMaleFemaleNon-binaryPrefer not to sayOtherStudent 1 RaceAmerican Indian or Alaska NativeAsianBlack or African AmericanHawaiian Native or Other Pacific IslanderMore than one raceWhitePrefer not to sayOtherStudent 1 Ethnicity Hispanic or LatinoNot Hispanic or LatinoPrefer not to sayStudent 1 BirthdateStudent 1 GradeStudents reaction to the death & grieving process since the death?Do you have another student to register?YesNoSecond StudentStudent 2 NameFirstLastStudent 2 GenderMaleFemaleNon-binaryPrefer not to sayOtherStudent 2 RaceAmerican Indian or Alaska NativeAsianBlack or African AmericanHawaiian Native or Other Pacific IslanderWhiteMore than one raceOtherPrefer not to sayStudent 2 Ethnicity Hispanic or LatinoNot Hispanic or LatinoPrefer not to sayStudent 2 Birthdate Student 2 GradeStudents reaction to the death & grieving process since the death?Do you have a third student to register? YesNoStudent 3 Name FirstLastStudent 3 GenderMaleFemaleNon-binaryPrefer not to sayOtherStudent 3 RaceAmerican Indian or Alaska NativeAsianBlack or African AmericanHawaiian Native or Other Pacific IslanderWhiteMore than one racePrefer not to sayOtherStudent 3 EthnicityHispanic or LatinoNot Hispanic or LatinoPrefer not to sayStudent 3 Birthdate Student 3 GradeStudent 3 reaction to the death & grieving process since the death? Information regarding the deathName of the person who died:FirstLastWhat is the Deceased relationship to Child?MotherFatherStep-FatherStep-MotherBrotherSisterGrandparentAuntUncleCousinFriendOtherDate of DeathCause of DeathCancerRespiratory DiseaseHeart DiseaseLiver DiseaseSuicideHomicideOverdoseCongenital/ Genetic DisorderAccidentMotor Vehicle AccidentPerinatal/StillbornCOVID 19Pneumonia/InfluenzaDementia/CerebrovascularOtherPrefer Not to AnswerPlease provide any other relevant details regarding the death here:Other significant deaths: Please include the name, relationship, age, date of death, circumstances of death, and information about the child's reaction below. Are you interested in hearing more about our other free grief support services?YesNoMedia Release: I do/do not (select below) consent for my child to participate in photographs, recorded videos, and interviews taken by Bridges personnel or school staff for the purpose of capturing and sharing Bridges’ program experiences for program promotion and fundraising. (Please be assured, Bridges takes confidentiality and privacy very seriously and will only use photos judiciously and appropriately).I DO consentI DO NOT ConsentPolicies & Consent for Participation Please read over the information below and sign your name electronically if you give consent I, the undersigned parent (or guardian) of the child named above (hereinafter referred to as “child”), give my consent for the child’s participation in Bridges programming. EMERGENCY CARE RELEASE: I authorize, that in an emergency situation, Bridges personnel/school staff to call emergency services. In the event that I cannot be reached or be present, I hearby authorize Bridges personnel/school staff to execute any and all documents including any necessary releases in my behalf which might be required by any medical facility to perform any emergency care on account of an accident or illness sustained or incurred by the child while participating in Bridges’ programming. I further agree that in consideration of my child participation in Bridges’ programming, I will hold Bridges for End-of-Life personnel/school staff harmless from any action by me, my child, or family members on account of any injury or damage sustained or suffered by my child while attending Bridges’ programming, and hereby waive any right of legal action against Bridges for End-of-Life. MANDATORY REPORTING: Bridges’ staff and volunteers will maintain all confidentiality when working with children. However, South Carolina law does require that any of us report suspected cases of abuse or neglect to ensure the safety of our community’s children. A report must happen if a volunteer or staff member has any reason to believe that a child’s physical or mental health has been, or may be, adversely affected by abuse or neglect. By signing below, you acknowledge you have read and agree to all items listed above. SignatureClear SignatureSubmit
