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.

Student Name*
First Last
Student Age*
School*
Referred by*
Student Date of Birth*
MM slash DD slash YYYY
Student Gender*
- Male
- Female
Student grade*
- 4th
- 5th
Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Name*
First Last
Parent/Guardian Phone*
Parent/Guardian Email*
Parent/Guardian Address if different than students
Street Address Address Line 2 City State ZIP Code
2nd Parent/Guardian Name if applicable
First Last
Transportation*
- I need CVCCS to provide transportation home for my child.
- I do not need CVCCS to provide transportation home for my child (*parent pick up is 5pm at CVCCS*).
Emergency Contact for student*
First Last
Emergency Contact Phone*
Emergency Contact Relation to Student*
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.
Doctor*
Doctor Phone*
Doctor Address*
Street Address Address Line 2 City State ZIP Code
Preferred Hospital*
Student Medications*
If none put NONE.
Student Allergies*
If none put NONE.
Medical Insurance Company*
Medical Insurance Policy #*
Insurance Company Address*
Street Address Address Line 2 City State ZIP Code
Permission to provide necessary treatment or emergency care*
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 Agree
Electronic Signature*
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
- I Agree.
Phone
This field is for validation purposes and should be left unchanged.

Rooted Afterschool Student Application

Medical Information: