2025/26 Registration Form

Rooted Youth
Jr High: Grades 6-8
Sr High: Grades 9-12

Wednesdays @ 6:30 - 8:30pm
269 Quarter Town Line (Bethel Pentecostal Church)
Beginning in September

Each night will consist of lesson time, worship, games and lots of fun!

Rooted Youth is a partnership between Bethel Pentecostal Church & North Broadway Baptist Church.

Registration Forms MUST be completed by parent/guardian PRIOR to attending youth on Wednesdays. Any students who do not have a registration form completed will not be able to participate in youth weekly or special events until one is completed.

This Registration Form expires September 2026.

Your name *

Email address *

Phone number *

Address *

Household members

I agree to medical consent *

The safety of your student is our primary concern. Precautions will be taken for their well-being and protection.

I/we, the parents or guardians named below, authorize Rooted Youth Personnel to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above. This authorization will only take place for emergency medical treatment and after we have tried and were unable to contact parents/guardians and emergency contacts provided in this form.

I/we, named below, undertake and agree to indemnify and hold harmless Rooted Youth Group Personnel and its Leaders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Rooted Youth Group, as well as of any medical treatment authorized by the supervising individuals representing the organization. This consent and authorization is effective only when participating in or traveling to events sponsored by Bethel & North Broadway Baptist Church Rooted Youth Group.

I agree to use of photos *

I give permission to utilize any photos and videos taken during Rooted Youth Group for photo collages, updates shared with parents, future youth group promotional material, websites, newsletters, or for the organization.

I agree to purposes and extent *

Rooted Youth Group is collecting and retaining this personal information for the purpose of enrolling your student in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child, and to inform you of program updates and upcoming opportunities at our organization. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish, Youth Group, to limit the information collected, or to view your student’s information, please contact us.

I understand that by clicking submit, it is equal to my signature. *

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