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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Email *
First Name of Youth *
Last Name of Youth *
2025-26 school grade *
Cell phone number of youth (if applicable)
E-mail address of youth
Birth date of youth *
MM
/
DD
/
YYYY
School *
Street Address (# and street only) *
City *
Zip *
Father's first and last name
Father's contact phone number
Father's e-mail (if you know it)
Mother's first and last name
Mother's contact phone number
Mother's e-mail (if you know it)
Church your family attends on Sundays (leave blank if not applicable)
Has your child confessed their faith in Jesus? *
Has your child been baptized? *
Additional comments/questions?
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