Rooted Student Application (*by referral ONLY*)

Before submitting this form, please click on the ROOTED POLICIES link below, review each item carefully, and provide your electronic signature at the end of this form.

Rooted Policies

Rooted Afterschool Student Application

If you have any questions, please contact Kimberlee Platchek, Student Ministries Director: 717-208-3711 x105 | assistant@cvccs.org.
  • MM slash DD slash YYYY
  • Medical Information:

    The intent of this information is to provide Rooted staff with background to provide appropriate care. Should any information change on this form, please advise the Rooted Director immediately.
  • If none put NONE.
  • If none put NONE.
  • I hereby give permission to the medical personnel selected by the Rooted Director to order X-rays, routine tests, or treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my student. In the event I cannot be reached in an emergency, I hereby give permission to the attending physician to administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips where participants are off-site.
  • I have read and agree with all of the policies (including Transportation and Photo Release), and I verify that the information I’ve provided is accurate and complete
  • This field is for validation purposes and should be left unchanged.