Stepping Stones Enrollment Building bridges of hope for lowcountry families since 1980 Please enable JavaScript in your browser to complete this form.Caregiver Information (parent or guardian)Name *FirstLastYour relationship to child(ren) *Mobile *Personal Email *What is the best way to reach you?PhoneEmailMailHow did you hear about us?Mailing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCounty *Would you like to add a secondary caregiver at this time?YesNoSecondary Caregiver Name FirstLastRelationship to Child/TeenSecondary Caregiver MobileSecondary Caregiver EmailBereavement InformationName of Deceased *FirstLastWhat is the Deceased relationship to Child? *Mother/Step-MotherFather/Step-FatherBrotherSisterGrandparentExtended Family (Aunt, Cousin, etc.)FriendOtherWhat is your relationship to the deceased? *PartnerFormer PartnerParentChildExtended FamilyOtherDate of DeathType of Death *Illness/DiseaseAccidentSuicideHomicideOverdoseNaturalUndeterminedPrefer Not to AnswerOtherPlease provide any other relevant details regarding the death here:Is there another significant death? YesNoName of secondary Deceased *FirstLastWhat is the Deceased relationship to Child? (secondary) *Mother/Step-MotherFather/Step-FatherBrotherSisterGrandparentExtended Family (Aunt, Cousin, etc.)FriendOtherSecondary Date of Death Secondary: Type of Death Illness/DiseaseAccidentSuicideHomicideOverdoseNaturalUndeterminedPrefer Not to AnswerOtherSecondary: provide any other relevant details regarding the death hereOther significant deaths: Please include the name, relationship, age, date of death, circumstances of death, and information about the child's reaction below. Child/Teen InformationChild/Teen Name *FirstLastGender *FemaleMaleNon-binaryPrefer not to sayRace or Ethnicity *American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoHawaiian Native or Other Pacific IslanderWhitePrefer not to sayOtherT-Shirt Size *Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult XXLBirthdate *School *This child/teen's reaction to the death & grieving process since the death?Do you have second child/teen to enroll?YesNoSecond Child/TeenSecond Child Name *FirstLastSecond Child Gender *FemaleMaleNon-binaryPrefer not to saySecond Child Race or Ethnicity *American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoHawaiian Native or Other Pacific IslanderWhitePrefer not to sayOtherSecond Child T-Shirt Size *Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult XXLSecond 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?YesNoThird Child/TeenThird Child Name *FirstLastThird Child Gender *FemaleMaleNon-binaryPrefer not to sayThird Child Race or Ethnicity *American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoHawaiian Native or Other Pacific IslanderWhitePrefer not to sayOtherThird Child T-Shirt Size *Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult XXLThird 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? YesNoFourth Child/Teen InformationFourth Child Name *FirstLastFourth Birthdate *Fourth Child Gender *FemaleMaleNon-binaryPrefer not to sayForth Child Race or Ethnicity *American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoHawaiian Native or Other Pacific IslanderWhitePrefer not to sayOther Fourth Child/Teen School *Fourth Child T-Shirt Size *Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult XXLFourth Birthdate (copy) *Fourth Child/Teen Reaction to the death & grieving process since the death? Do you have a fifth child/teen to enroll?YesNoFifth Child/Teen InformationFifth Child Name *FirstLastFifth Birthdate *Fifth Child Gender *FemaleMaleNon-binaryPrefer not to sayFifth Child Race or Ethnicity *American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoHawaiian Native or Other Pacific IslanderWhitePrefer not to sayOther Fifth Child/Teen School *Fifth Child T-Shirt Size *Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult XXL Fifth Child/Teen School *Fifth Child/Teen Reaction to the death & grieving process since the death? Other Family InformationIs there anything else that you feel is important for us to know about your family?Policies & Consent for ParticipationMedia 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 consentI DO NOT consentI, 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. SignatureClear SignatureBy 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 SurveyOur family speaks openly about their feelings and emotionsNeverSometimesAlwaysNot SureOur family is familiar with healthy coping skillsNeverSometimesAlwaysNot SureOur family communicates with one another openly.NeverSometimesAlwaysNot SureTogether we shares stories/memories of the deceasedNeverSometimesAlwaysNot SureWe feel comfortable asking each other questions about the death or deceasedNeverSometimesAlwaysNot SureTogether, we talk about our goals for the futureNeverSometimesAlwaysNot SureNotes or any additional explanation or observances:Next Steps: Schedule a Orientation with our Program StaffIf 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! Submit Get Started Enroll Complete the Stepping Stones Membership Form Schedule Schedule time with our staff to discuss your needs & our support l Register Sign-up to attend one of our activities or events
