NURSERY INFORMATION FORM 2025

First Congregational Church in Winchester

21 Church Street Winchester MA 01890

(781)729-9180
NURSERY INFORMATION FORM

(For infants and toddlers)
Child's Name:*

First NameLast Name
Preferred Name (if different):*
Child's Date of Birth:*

MonthDayYear
Child's Gender:*
Parent/Guardian's Name:
Parent/Guardian's Name:*

First NameLast Name
Parent/Guardian's Email:*
example@example.com
Parent/Guardian's Cell Phone #:

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Names and ages of child's siblings:*
List all special needs or allergies that we should be aware of to help us care for your child's health*
Please describe your child's potty training.*

In diapersWorking on potty trainingPotty trainedOther
Do we have permission to change your child's diaper?*

YesNoOther
Do we have permission to take your child to the restroom and remain at the door? The door will remain open just enough to allow for privacy but also to provide assistance to the child if needed.*

YesNoOther
In order to share the good news of the ministries of the church, we sometimes take photos of children and youth for use on bulletin boards, in our newsletters and on our website. When published on our website we do not include any identifying information (name, address, etc.) about the child along with the photo. Do you authorize the use and reproduction of your child's photo(s) by the church?*

YesNo
I understand that every effort will be made to contact parents/guardians in the event of an emergency. In an emergency requiring medical care and treatment, I authorize any physician, hospital or other healthcare provider to give care to this minor. I also give permission for the transport of my child to/from a doctor and/or hospital by a chaperone or ambulance.
Parent's/Guardian's signature:*

Clear
Date:

MonthDayYear
Date
Should be Empty: