Roots & Wings Registration
Children Ages 6 - 11 Years Old
Children Details
Child #1 Name
*
First Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's T-Shirt Size
*
Please Select
Youth X-Small
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Upload Current Photo of Child:
*
Browse Files
This photo will NOT be used on any social media platform. This is to help the Ministry's staff to keep account of all children and connect with them.
Cancel
of
Is there another child to sign up?
Please Select
Yes
No
Child #2 Name
*
First Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's T-Shirt Size
*
Please Select
Youth X-Small
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Upload Current Photo of Child:
*
Browse Files
This photo will NOT be used on any social media platform. This is to help the Ministry's staff to keep account of all children and connect with them.
Cancel
of
Is there another child to sign up?
Please Select
Yes
No
Child #3 Name
*
First Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's T-Shirt Size
*
Please Select
Youth X-Small
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Upload Current Photo of Child:
*
Browse Files
This photo will NOT be used on any social media platform. This is to help the Ministry's staff to keep account of all children and connect with them.
Cancel
of
Parent/Guardian Information
Paren/Guardian Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Emergency Contact Information
Emergency Phone Name
*
First Name
Last Name
Emergency Phone Number
*
-
Area Code
Phone Number
Relationship to Child(ren)
*
Medical Information
Primary Care Physician
First Name
Last Name
Physician's Phone Number
-
Area Code
Phone Number
Does the child(ren) have any allergies (food, medication, environmental)?
*
Please Select
Yes
No
Please name the child(ren) and the allergies associated with them.
Does the child(ren) have any chronic conditions or illnesses (e.g. asthma, diabetes, epilepsy)?
*
Please Select
Yes
No
Please name the child(ren) and the chronic conditions associated with them.
Does the child(ren) currently take any medications?
*
Please Select
Yes
No
Please name the child(ren) and the medications associated with them.
If the child(ren) need to take medication(s) during meetings, please state instuctions so we can ensure the best safety of the child(ren).
Has the child(ren) recieved the following vaccinations? Please check the box for YES.
Tetanus
Measles, Mumps, Rubella (MMR)
Chickenpox (Varicellea)
Hepatitis B
Other
Please list an other vaccinations we need to know about:
Dietary Restrictions
Do the child(ren) have any dietary restrictions?
*
Please Select
Yes
No
Please name the child(ren) and their dietary restrictions.
Emergency Authorization
In the event of an emergency, I hererby authorize the ministry staff to ensure medical treatment for the child(ren), including transportation to the nearest medical facility if necessary. I understand that every effort will be made to contact me or the emergency contact provided before such action is taken.
*
Please Select
Yes
No
Permissions
I give permission for my child(ren) to participate in all social activites. I will speak with Lisa Duncan (Youth Director) if there is an issue with any of the follow activities.
*
Please Select
Yes
No
I give permission for my child(ren) photos to be taken and used for the ministry's social promotion materials.
*
Please Select
Yes
No
Please note anything not mentioned in the form about the child(ren). We want to take care and ensure the BEST safety for the group.
Payment
My Products
*
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Roots & Wings Club
Kids club with a one-time fee for the year. The children learn hands-on skills, with fun activities and gain life experiences. Meetings are every Wednesday from 6:30 pm - 7:30 pm. Parents are welcome to join the children at no additional costs.
$
50.00
Payment Methods
Credit Card
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Please sign for authorization and all information above is true.
*
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