• First Congregational Church in Winchester

    21 Church Street Winchester MA 01890

    (781)729-9180

  • YOUTH INFORMATION FORM

    For middle school and high school students
  • 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.

  •  / /
    Pick a Date
  •  -
  •  -
  •  -
  • 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.

  • 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.

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

  • Should be Empty: