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Roots Youth Information & Media Release form
Please fill this form out once per year or in the event of a change.
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* Indicates required question
Email
*
Your email
First Name of Youth
*
Your answer
Last Name of Youth
*
Your answer
2025-26 school grade
*
6
7
8
9
10
11
12
Cell phone number of youth (if applicable)
Your answer
E-mail address of youth
Your answer
Birth date of youth
*
MM
/
DD
/
YYYY
School
*
Your answer
Street Address (# and street only)
*
Your answer
City
*
Your answer
Zip
*
Your answer
Father's first and last name
Your answer
Father's contact phone number
Your answer
Father's e-mail (if you know it)
Your answer
Mother's first and last name
Your answer
Mother's contact phone number
Your answer
Mother's e-mail (if you know it)
Your answer
Church your family attends on Sundays (leave blank if not applicable)
Your answer
Has your child confessed their faith in Jesus?
*
Yes
No
Other:
Has your child been baptized?
*
Yes
No
Maybe
Other:
Additional comments/questions?
Your answer
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