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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
Today's date
MM
/
DD
/
YYYY
First Name of Youth
Your answer
Last Name of Youth
Your answer
Current grade/year in school
Your answer
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:
Clear selection
Has your child been baptized?
Yes
No
Maybe
Other:
Clear selection
Any other comments/questions/suggestions/etc.
Your answer
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