* Indicates required question

    Parent Name *

    Parent Cell Phone Number *

    Email *

    Home Address *

    Student Name *

    Gender *

    Student Birthday *

    Student Age *

    Emergency Contact 1 (First/Last Name, Relationship, Phone Number) *

    Emergency Contact 2 (First/Last Name, Relationship, Phone Number) *

    Authorized Pick-Up (First/Last Name, Relationship, Phone Number) *

    Health Information? Include Dietary Restrictions and Allergies *

    First choice of Drop-in Day? (Friday's in August- May) *

    (Example: January 7, 2019)

    Second choice of Drop-in Day? (Friday's in August- May) *

    (Example: January 7, 2019)

    Which grade is your child currently in?
    Check all that apply.

    I have read over the Rooted in Faith Handbook and will return the parent signature page. *