Roots Registration
Starting Wed Sept 11!
Please fill out one form for each individual student that will be attending Roots 2019-2020.
Contact the church with any questions: 785-584-6351
Name (First, Middle, Last) *
Your answer
Primary Address *
Your answer
Primary Phone Number *
Your answer
Alt. Phone Number
Your answer
Email *
Your answer
Student Date of Birth *
MM
/
DD
/
YYYY
Student Age *
Your answer
Student Grade *
Your answer
Legal Guardian(s) Name (s) *
Your answer
Emergency Contact (Other than Guardian) Name *
Your answer
Emergency Contact (Other than Guardian) Phone *
Your answer
Emergency Contact (Other than Guardian) Relationship *
Your answer
Medical Insurance *
Your answer
Member Number *
Your answer
Allergies
Your answer
Medications
Your answer
Physicians Name *
Your answer
Physicians Phone *
Your answer
Other individuals that can take your child(ren) home OR if they are allowed to walk home: *
For the safety of your student(s) we will not allow them to go home with anyone not listed below without confirmation from you, as the guardian.
Your answer
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