YOUTH INFORMATION FORM 2023-2024

First Congregational Church in Winchester

21 Church Street Winchester MA 01890

(781)729-9180

This form requests contact and medical information for use throughout the current school year for youth participating in the First Congregational Church in Winchester youth programs and activities. Information provided in this document will be kept on file at the church and transported with youth leaders and chaperones to off-site trips. Should any of this information change over the course of the school year, please contact the Minister of Children & Families, Maggie Keeler at maggie.fccw@gmail or 617-821-7368.

Youth's Name:*

First NameLast Name

Nickname (if applicable)

Youth's gender*

Youth's preferred pronouns*

Youth's Birth date:*

Date

Youth's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Youth's Cell Phone Number*

Area CodePhone Number

Youth's Email Address:*

example@example.com

School Attending:*

HS Graduation Year:*

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Address (if different than youth)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Cell Phone Number*

Area CodePhone Number

Parent/Guardian Email Address:*

example@example.com

Emergency Contact Name:*

First NameLast Name

Emergency Contact Phone:*

Area CodePhone Number

Emergency Contact Relationship to Child: *

Youth's Doctor's name and Phone #:*

Health Insurance Company Name:*

Health Insurance Policy #:*

Please list youth's allergies, physical limitations, and health concerns of which we should be aware:*

Does your youth carry an emergency inhaler and/or epipen?*

YesNo

If your child has an emergency epi-pen, inhaler or medication they may need to take during regular programs, you must complete the Medication Release Form.

Please list any additional comments and information about your child that would be helpful for us to know about.*

PLEASE SELECT ONE OR MORE OF THE FOLLOWING OPTIONS*

Send all communications to parents/guardians only and we will forward to our youthSend all communications to both parents/guardians and youth

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(ren)'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.

Signature*

Clear

Date*

Date

If there are other concerns or information not included on this form that you wish us to know, please contact a minister.