ROOTED, Teen Ministry

Student Name

Birthdate

Grade Going Into

Parent / Guardian Contacts

Parent / Guardian Name (s)

Phone #1

Phone #2

Email #1

This address will receive a confirmation email

Email #2

This address will receive a confirmation email

Address

Authorized Pick Up Person and Relationship to Student:

Emergency Contact name and number and relationship to child

About the Student

Any Allergies or Health Issues

YES NO

Specify Allergies and if EpiPen is needed.

Student's Favorite Hobbies / Activities?

What Shirt Size? We are ordering one for him/her.

What church do you attend?

Waivers

Occasionally your child’s ROOTED leader would like to contact your child to see how they are enjoying club and if they need any help in completing their handbooks. He/she would also like to send written correspondence such as “Get Well” cards and a “Birthday” card. We are asking your permission as the legal parent/guardian to contact your child by a home visit, written communication, or phone call to discuss club activities.

YES

Photographs are sometime taken of Youth Ministry activities for publication and promotional purposes, which include, but are not limited to, in-house presentations, church websites, and church newsletters. Children’s names or information are never used without specific permission. By signing this area you are releasing Wilton Baptist to use photographs of your child as stated above.

YES Yes, I'm Very Photogenic!

I am adhering to the following Permission and Liability Release- I hereby give permission for the listed participant above to participate at Wilton Baptist Church in ROOTED Youth Ministry. I assume all risks which may be involved in the participant's involvement in the activities of Wilton Baptist Church. I hereby release Wilton Baptist Church, its directors, employees, agents, and members from any liability, claims, or demands of any nature whatsoever which may be incurred while this person is participating in the activities of Wilton Baptist Church.

Yes

Registration Payment/Donation

Date

Digital Signature of Parent/Guardian

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Please fill out this ROOTED Youth Ministry Student Form and click submit.

ROOTED begins Sunday, September 15.
Sunday nights during the school year, 5:00 PM - 6:30 PM

We are looking forward to a great year of Bible discipleship!

ROOTED, Teen Ministry

Description

Please Fix the Following