Roots & Wings Registration

Roots & Wings Registration

Children Ages 6 - 11 Years Old
Children Details
Child #1 Name*

First NameLast Name
Child's Birthday *

MonthDayYear
Date
Child's T-Shirt Size*
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. Cancelof
Is there another child to sign up?
Child #2 Name*

First NameLast Name
Child's Birthday *

MonthDayYear
Date
Child's T-Shirt Size*
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. Cancelof
Is there another child to sign up?
Child #3 Name*

First NameLast Name
Child's Birthday *

MonthDayYear
Date
Child's T-Shirt Size*
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. Cancelof
Parent/Guardian Information
Paren/Guardian Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Emergency Contact Information
Emergency Phone Name*

First NameLast Name
Emergency Phone Number*

Area CodePhone Number
Relationship to Child(ren)*
Medical Information
Primary Care Physician

First NameLast Name
Physician's Phone Number

Area CodePhone Number
Does the child(ren) have any allergies (food, medication, environmental)?*
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 name the child(ren) and the chronic conditions associated with them.
Does the child(ren) currently take any medications?*
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).
TetanusMeasles, Mumps, Rubella (MMR)Chickenpox (Varicellea)Hepatitis BOther
Please list an other vaccinations we need to know about:
Dietary Restrictions
Do the child(ren) have any dietary restrictions?*
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. *
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.*
I give permission for my child(ren) photos to be taken and used for the ministry's social promotion materials.*
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*

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

Enter coupon

Total

$0.00

Payment Methods

Credit Card

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Please sign for authorization and all information above is true. *
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Roots & Wings Registration

Children Details

Parent/Guardian Information

Emergency Contact Information

Medical Information

Dietary Restrictions

Emergency Authorization

Permissions

Payment

Payment Methods