Enrollment: Stepping Stones

Caregiver Information (parent or guardian)

Name *

First

Last

Your relationship to child(ren) *

Mobile *

Personal Email *

What is the best way to reach you?

Phone
Email
Mail

How did you hear about us?

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Would you like to add a secondary caregiver at this time?

Yes
No

Secondary Caregiver Name

First

Last

Relationship to Child/Teen

Secondary Caregiver Mobile

Secondary Caregiver Email

Bereavement Information

Name of Deceased *

First

Last

What is the Deceased relationship to Child? *

What is your relationship to the deceased? *

Date of Death

Type of Death *

Please provide any other relevant details regarding the death here:

Is there another significant death?

Yes
No

Name of secondary Deceased *

First

Last

What is the Deceased relationship to Child? (secondary) *

Secondary Date of Death

Secondary: Type of Death

Secondary: provide any other relevant details regarding the death here

Other significant deaths: Please include the name, relationship, age, date of death, circumstances of death, and information about the child's reaction below.

Child/Teen Information

Child/Teen Name *

First

Last

Gender *

Race or Ethnicity *

T-Shirt Size *

Birthdate *

School *

This child/teen's reaction to the death & grieving process since the death?

Do you have second child/teen to enroll?

Yes
No

Second Child/Teen

Second Child Name *

First

Last

Second Child Gender *

Second Child Race or Ethnicity *

Second Child T-Shirt Size *

Second Child Birthdate *

Second Child child/teen's reaction to the death & grieving process since the death?

School *

Do you have third child/teen to enroll?

Yes
No

Third Child/Teen

Third Child Name *

First

Last

Third Child Gender *

Third Child Race or Ethnicity *

Third Child T-Shirt Size *

Third Birthdate *

Third Child/Teen School *

Third Child/Teen Reaction to the death & grieving process since the death?

Do you have a fourth child/teen to enroll?

Yes
No

Fourth Child/Teen Information

Fourth Child Name *

First

Last

Fourth Birthdate *

Fourth Child Gender *

Forth Child Race or Ethnicity *

Fourth Child/Teen School *

Fourth Child T-Shirt Size *

Fourth Birthdate (copy) *

Fourth Child/Teen Reaction to the death & grieving process since the death?

Do you have a fifth child/teen to enroll?

Yes
No

Fifth Child/Teen Information

Fifth Child Name *

First

Last

Fifth Birthdate *

Fifth Child Gender *

Fifth Child Race or Ethnicity *

Fifth Child/Teen School *

Fifth Child T-Shirt Size *

Fifth Child/Teen School *

Fifth Child/Teen Reaction to the death & grieving process since the death?

Other Family Information

Is there anything else that you feel is important for us to know about your family?

Policies & Consent for Participation

Media Release: I do/do not (select below) consent for my child to participate in photographs, recorded videos, and interviews taken by Bridges personnel or school staff for the purpose of capturing and sharing Bridges’ program experiences for program promotion and fundraising. (Please be assured, Bridges takes confidentiality and privacy very seriously and will only use photos judiciously and appropriately). *

I DO consent
I DO NOT consent

I, the undersigned parent (or guardian) of the child/teen named above (hereinafter referred to as “child”), give my consent for the child’s participation in Bridges programming.

EMERGENCY CARE RELEASE: I authorize, that in an emergency situation, Bridges personnel/school staff to call emergency services. In the event that I cannot be reached or be present, I hearby authorize Bridges personnel/school staff to execute any and all documents including any necessary releases in my behalf which might be required by any medical facility to perform any emergency care on account of an accident or illness sustained or incurred by the child while participating in Bridges’ programming. I further agree that in consideration of my child participation in Bridges’ programming, I will hold Bridges for End-of-Life personnel/school staff harmless from any action by me, my child, or family members on account of any injury or damage sustained or suffered by my child while attending Bridges’ programming, and hereby waive any right of legal action against Bridges for End-of-Life.

MANDATORY REPORTING: Bridges’ staff and volunteers will maintain all confidentiality when working with children. However, South Carolina law does require that any of us report suspected cases of abuse or neglect to ensure the safety of our community’s children. A report must happen if a volunteer or staff member has any reason to believe that a child’s physical or mental health has been, or may be, adversely affected by abuse or neglect. By signing below, you acknowledge you have read and agree to all items listed above.

Signature

By entering your name below, you acknowledge that everything on this application is correct and you want to move forward with processing your family's enrollment to the Stepping Stones Grief Support Program.

Family Grief Survey

Our family speaks openly about their feelings and emotions

Never
Sometimes
Always
Not Sure

Our family is familiar with healthy coping skills

Never
Sometimes
Always
Not Sure

Our family communicates with one another openly.

Never
Sometimes
Always
Not Sure

Together we shares stories/memories of the deceased

Never
Sometimes
Always
Not Sure

We feel comfortable asking each other questions about the death or deceased

Never
Sometimes
Always
Not Sure

Together, we talk about our goals for the future

Never
Sometimes
Always
Not Sure

Notes or any additional explanation or observances:

Next Steps: Schedule a Orientation with our Program Staff

If you choose not to schedule a call now, you will have an link to schedule in your confirmation email. Orientation call must be complete prior to attendance to any of our programs. Thank you!