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Stepping Stones Drop In

This form is for approved use only.  The Stepping Stones program is not a drop in care service, however in case of an emergency, this form provides the information we need to keep your child safe.  Please complete this form only after speaking with the preschool staff.

Payment for this service will be billed separately from tuition. Your FACTS account can be used for payment or you can pay by check or cash.

Student Name *
Birthdate *
 /  / 
Gender *
Preschool Class: *
Mothers Name: *
Mothers Phone: *
Fathers Name: *
Fathers Phone: *
Primary Email: *
Allergies: *
If Yes, Please List:
Emergency Contact Name and Phone Number(other than parents): *
I give permission for my child to be picked up by: (list name, relation, and phone number) *

Please read the following statement and acknowledge receipt by checking the box.

Please acknowledge the following statements and agree by checking the box. *
Date Needed: *
 /  / 
Select the slots you are requesting (call for availability) *
Comments or Special Instructions:
Word Verification:
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