Bridge Fund Application Form



Contact's Information:

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Street Address City State Postal Code


Volunteers under 18 are required to obtain parent/guardian consent.



Parent/Guardian's Information:




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Primary Medical Provider/Doctor Contact Information:



Email is an efficient and inexpensive way for us to communicate with you. We'll never share or sell your information, and you can unsubscribe at any time.

Street Address City State Postal Code

Financial Assistance Requested:







Email is an efficient and inexpensive way for us to communicate with you. We'll never share or sell your information, and you can unsubscribe at any time.

Street Address City State Postal Code
Applicant/Guardian Release


Information and Photos:


By signing this application, I give EFMN permission to use my image and biographical information in photos and promotional materials for the purpose of promoting EFMN and its services.

 

Assumption of Risk and Release of Liability:


I, for myself and on behalf of the applicant (if applicant’s guardian), am aware of, understand, and assume any and all risks inherent in use of any and all products and/or services received under or in conjunction with funds received from EFMN. I agree to hold harmless and release EFMN, its board, its employees, and others acting on EFMN’s behalf, of all claims, demands, causes of action and legal liability, whether the same be known or unknown, anticipated or unanticipated, due to providing said product and/or services. I further agree that I shall not bring any claims, demands, legal actions and causes of actions against EFMN and its associates, as stated above in the same clause, for any economic and/or non-economic losses due to bodily injury, death, property damage and injury to, or loss by death for use of said products/services. The EFMN makes no warranties or guarantees of any kind, implied or actual, as to the function, suitability, safety, or intended use of said products/services.