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ROOTS
After School Program
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* Indicates required question
Child's Name (first and last)
*
Your answer
Child's Age
*
Your answer
Contact Email
*
Your answer
Contact Phone Number
*
Your answer
Child Pick-Up or Release After ROOTS
*
A Parent/Guardian will pick up child each week
Child may leave independently each week
Required
If your child will be picked up by a parent or guardian from ROOTS, please indicate who has permission to pick them up (name and relationship).
Your answer
Does your child have allergies? If yes, please list.
*
No
Yes
Required
If you answered "Yes" above, please list the allergies below
Your answer
Does your child have medical conditions or special needs that we should be aware of? If so, please explain.
Your answer
I (parent/guardian) give permission to Minnedosa Evangelical Covenant Church to use photos taken at ROOTS which include my child for social media or website program promotion use.
*
Yes
No
Required
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