Bridge Academy - Admissions Application

Bridge Academy - Admissions Application

Thank you for your interested in the BDI Bridge Academy IT Certification Program. This application must be completed by the Potential Student or Legal Guardian only. If you are someone other than the Potential Student or Legal Guardian, please do not complete this application.

Please note that this program is designed for individuals living with a disability ages 18 or over. BDI requires documentation of eligibility for this program including:

Verification of completion of high school or high school equivalent.
Verification of disability. Documents providing verification of disability must be attached in order for the application to be accepted.

Please complete the application information below.

CONFIDENTIALITY STATEMENT

It is the policy of BDI to ensure the confidentiality of the individuals we serve in compliance with HIPAA and other federal and state laws regarding Confidentiality and Privacy Practices. Any information entered on the application may not be shared with another person or agency without you prior knowledge and written consent.

Demographic Information

Applicants Full Name:*

First Name, Middle Initial, Last Name (ex. John A. Doe)

Please list the name that you prefer to go by:

I am a:*

Potential Student

Legal Guardian

Address 1:*

Address 2:

City:*

State:*

Zip Code:*

Phone*

Phone

Type of Phone*

Cell Phone

Home Phone

Alternative Phone

Phone

Email:*

Do you authorize BDI to communicate with you via email?*

Yes

Date of Birth:*

Date of Birth

Year of Birth

Age:*

Gender:*

Male

Female

Other

If you selected other, please list the gender you identify as below:

Ethnicity/Hispanic Origin:*

Hispanic/Latino

Non Hispanic/Latino

Do you need interpreter services?*

Yes

Are you a citizen of the U.S.?*

Yes

Are you living with a documented disability?*

Yes

If applicable, please list any accommodations that you have or need:

BDI requires verification of disability status. Please select the following records you are able to provide. Please note that documents providing verification of disability must be attached in order for the application to be accepted. (Select all that apply)*

Legal Guardian Information, if applicable

Do you have a Legal Guardian?*

If no, please skip to the Education and Work History Section.

If yes, please complete the information below.

Yes

Legal Guardian Name

Guardian Phone Number

Phone

Guardian Email

Do you authorize BDI to communicate with you via email?

Yes

Address same as above?

If your address is the same as the potential student please check here. If not please complete the address information below.

Guardian Address 1

Guardian Address 2

Guardian City

Guardian State

Guardian Zip Code

Education and Work History

Do you have documentation of your education (diploma/transcript) that you can provide.*

Yes

Are you legally able to work in the U.S.?*

Yes

If no, please explain:

Are you a veteran?*

Yes

Are you currently employed?*

Yes

If yes, where?

Have you previously worked?*

Yes

If yes, where did you previously work?

Do you have any background in Technology that you think would be relevant for this program?:*

Yes

If yes, please describe your background in Technology below:

Are you currently enrolled with GA Vocational Rehabilitation Services (GVRA)?*

Yes

If yes, please list the name of your GVRA Counselor below:

Please enter your GVRA Counselor's email below (if applicable):

Please enter your GVRA Counselor's contact number below (if applicable):

Phone

Are you currently enrolled with Veteran Affairs Services (VA)?

Yes

If yes, please list the name of your VA Counselor below:

Please enter your VA Counselor's email below (if applicable):

Please enter your VA Counselor's contact number below (if applicable):

Phone

Release of Information

Authorization to Release and Obtain Confidential Information*

I understand that my records are protected under the Federal and State Confidentiality regulations and cannot be released without my written consent unless otherwise provided for in the regulations. Federal regulations prohibit BDI from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.

I further understand that my services are not contingent upon, or influenced by my decision to permit the information release, and by signing below, I indicate that my consent to the release of this information is given freely and voluntarily.

Please select below if you authorize BDI to obtain records on your behalf from the indicated school, agency, or individual below.

I hereby DO authorize BDI to obtain, to release, communicate, and exchange information or records on my behalf as indicated below.

I hereby DO NOT authorize BDI to obtain, to release, communicate, and exchange information or records on my behalf as indicated below.

I authorize BDI to communicate with the following agencies (Select all that apply):*

Georgia Vocational Rehabilitation Agency

Department of Behavioral Health and Developmental Disabilities (DBHDD)

Department of Veteran Affairs (VA)

Parent, Legal Guardian, or Authorized Representative

Other (Please specify below)

I do not authorize BDI to communicate with any agency regarding my information.

Please list the name of agencies or individuals (Third Party) that you authorize BDI to obtain, to release, communicate with, and exchange information or records. (ex. ABC Medical Group, Dr. John Doe, Parent, Employer, etc.).

Notice regarding educational records:

If the records to be disclosed are education records (which may include discipline records), they are maintained and released in accordance with the Family Educational Rights and Privacy Act (FERPA). Parents or eligible students shall be provided a copy of the records to be disclosed if requested. Redisclosure, except as provided at 34 CFR § 99.31, requires prior consent of parents or eligible students.

Please list your school's name or educational institution below:

Purpose of Disclosure*

Other Purpose of Disclosure

Specify below if you selected "other" above.

I authorize BDI to obtain records on my behalf for the following time period.*

Ninety (90) days

One (1) year

The period necessary to complete all transactions on accounts related to services provided to me

I do not authorize release of any records.

Person Completing Form Is:*

Potential Student

Legal Guardian

Release of Information Signature*

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document and authorize BDI to obtain, to release, communicate with, and exchange information or records identified in the release of information section.

Please note that if you indicated above that you do not authorize the release of records that this signature line acts as verification for BDI to not obtain records on your behalf.

Please type your name below:

Program Commitment

Please describe why you are interested in participating in this IT Certification Program?*

Time Commitment Acknowledgement*

Please review the program time commitments below:

Program Dates: 2025 Start Dates are Pending

Program Schedule

Days Per Week: Monday thru Friday (5 days a week)

Remote Classes: 4 Days a week delivered virtually
Onsite Classes: 1 Day a week of onsite lab work

Time: 8:00 am - 3:00 pm (7 hours a day of Class Time)

Additional Requirements: Homework

Expect 2-hours daily for homework tasks

Are you able to fully commit to the program requirements listed above?

Yes

This program is partially remote and requires that the individual has access to a computer and internet services.*

Do you have access to a computer and internet services?

Yes

Do you have any foreseen circumstances or concerns regarding the information above that might hinder your commitment? (Check all that apply)*

If you selected other above, please describe the concerns:

Do you have reliable transportation?*

Yes

If no, please explain your current obstacles with transportation:

Documents

Documents providing verification of disability must be attached in order for the application to be accepted. Acceptable documents include:

DBHDD I&E Assessment
School IEP
Social Security Disability Letter of Determination
Medical Verification for identified disability
Documents of Diagnosis for identified disability

If you have any of the following documents available please upload them in the File Upload below:

Transcripts
High School Diploma/Certificate of Completion
GVRA Authorization Form
GVRA Eligibility Determination Form
GVRA Individual Plan for Employment
VA Authorization for Services form

Please select the Documents of Disability you are providing (select all that apply):*

Psychological Evaluation

School IEP

Social Security Disability Determination

Medical Verification

DBHDD I&E Assessment

NA: Please note your application will not be accepted, without documentation verifying disability.

File Upload*

Drag and drop files here or

Background Check Consent Form

The goal of the Bridge Academy is to provide training and Information Technology certification and to help with job placement in Information Technology positions. BDI works with multiple Information Technology companies across the Atlanta Metro Area. In order to expedite job, internship, and or apprenticeship placement, We ask that you complete the authorization for Background Check Form below:

Background Check Authorization*

I hereby DO authorize Bobby Dodd Institute to receive any Georgia criminal history information pertaining to me, which may be in files of any state or local criminal agencies in Georgia.

I hereby DO NOT authorize Bobby Dodd Institute to receive any Georgia criminal history information pertaining to me, which may be in files of any state or local criminal agencies in Georgia.

Please enter your 9 Digit Social Security Number:*

Please enter your height:*

Please enter your eye color:*

This authorization is valid for:*

180 Days from Signature

I do not authorize BDI to conduct a background check.

Person Completing Form:*

Potential Student

Legal Guardian

Background Check Signature*

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

Please type your name below:

Image and Photo Release and Use Agreement

Image and Photo Release and Use Agreement*

I hereby grant and authorize Bobby Dodd Institute (BDI) the unrestricted right to take, edit, alter, copy, exhibit, publish, distribute, reproduce, and make use of any and all pictures, or video taken of me to be used in and/or for promotional materials. This includes but is not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalist, websites, social networking sites, and other print and digital communications, without payments or other considerations. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used. This authorization extends to all languages, media, formats, and markets now known or hereafter devised. I understand and agree that these images shall become the property of Bobby Dodd Institute, and will not be returned.

Furthermore, I grant permission to use my statements that were given during an interview or survey, with or without my name, for the purpose of advertising and publicity without restriction. I understand and agree that BDI may use information regarding my health condition, including information regarding my diagnosis, services receiving/received, my date of birth and/or age and my other relevant disability information/conditions, in describing the services rendered to me as depicted in any image of me. I understand and agree that these statements shall become the property of BDI, and will not be returned.

This authorization shall continue indefinitely and in perpetuity, unless I otherwise revoke said authorization in writing.

I understand that BDI will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand, however, that BDI cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I hereby agree to release, defend, and hold harmless Bobby Dodd Institute and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages, petitions, or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I attest that BDI has not conditioned the rendition of services to me upon my authorization of the use of my image and/or likeness and or statements.

I DO authorize and give BDI permission to use of my image, likeness, and/or statements.

I DO NOT authorize BDI permission to use of my image, likeness, and/or statements.

Person Authorizing Use of Image and Photo Release*

Potential Student

Legal Guardian

Image and Photo Release Signature*

I am 18 years of age or older (or am the Parent/Legal Guardian) and I am competent to contract in my own name. I have read the foregoing in its entirety and understand its terms, before signing below, and I fully understand the terms, conditions, contents, meaning and impact of this release.

Application Submission

Do you understand that all applicants may not be accepted into this program?*

Yes

Application Acknowledgment Statement*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

Electronic Signature*

ACKNOWLEDGEMENT: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document and authorize BDI to obtain any indicated documentation identified in the release of information section.

Please type your full name below.

Please indicate who is signing this application*

Potential Student

Legal Guardian

Thank you for completing the BDI Bridge Academy Application.

We recommend that you check the box below marked "Send me a copy of my responses." By checking this box a copy of your completed application and attachments will be emailed to you for your records.

We look forward to working with you!

Send me a copy of my responses

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