STEPPING STONES INFO FORM 2025

First Congregational Church in Winchester

21 Church Street Winchester MA 01890

(781)729-9180
STEPPING STONES INFORMATION FORM

For children in Pre-K through fifth grade
For infants and toddlers, please complete a separate Nursery Information Form. For youth (middle school and high school students), please complete a Youth Information Form. A separate form for each child must be filled out.
Child's Name:*

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

MonthDayYear
Date
Child's Gender:*
Child's Preferred Pronouns:*
Name of School Attending:*
Current Grade for 2024-2025:*

Pre-KKindergarten1st2nd3rd4th5th
Parent/Guardian's Name*

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

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone:*

Area CodePhone Number
Relationship of Emergency Contact to Child:*
Name and telephone number of Child's doctor:*
Health Insurance Company Name:*
Health Insurance Policy Number:*
Please list your child's allergies, physical limitations, and health concerns of which we should be aware:*
Does your child have an emergency epipen, inhaler or other medication they may need to take during regular programs?*

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 special learning needs of which we should be aware. (We want to nurture your child's learning and will only share information with teachers as need.)*
Please list any additional comments and information about your child that would be helpful for us to know about (fears, special instructions, problems, behaviors, etc.).
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.
Parent's/Guardian's signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

STEPPING STONES INFORMATION FORM