Roots to Rise Registration 2026

Youth Name

First NameLast Name
Grade
List any allergies (i.e. seasonal, food, sunscreen, insect bites or stings, If none, enter N/A)
Does this child have any medical conditions?
If yes to either of the above, describe the action plan for your child.
Will this child need to take medication while at our program? All medication must be brought in the original container.
Do you give permission for Stand In For Nebraska and related organizations to apply sunscreen and bug spray of their choice to your minor child following the directions or recommendations printed on the bottle?
I have provided the following brand/type of sunscreen or bug spray for use on my child (if not applicable type NA)
For medical or other reasons, please do not apply sunscreen or bug spray to the following areas of my child's body (if not applicable, type NA)
Are there any other needs or information the staff should know about the child prior to camp that would help your child have a successful experience? Please explain or type NA if none.
Add Another Child?

Youth Name

First NameLast Name
Grade
List any allergies (i.e. seasonal, food, sunscreen, insect bites or stings; If none, enter N/A).
Does this child have any other medical conditions?
If yes to either of the above, please describe the action plan for your child
Will this child need to take medication while at our program? All medication must be brought in the original container.
Do you give permission for Stand In For Nebraska and related organizations to apply sunscreen and bug spray of their choice to this minor child following the directions or recommendations printed on the bottle?
I have provided the following brand/type of sunscreen or bug spray for use on my child (if not applicable type NA)
For medical or other reasons, please do not apply sunscreen or bugspray to the following areas of my child's body (if not applicable, type NA)
Are there any other needs or information the staff should know about the child prior to camp that would help your child have a successful experience? Please explain or type NA if none.

Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Mobile Number
Format: (000) 000-0000.
Can text messages be received at the mobile number?
E-mail
example@example.com
I have talked to my child(ren) and they have expressed they want to attend camp. If not, please do not reserve a spot at camp.

Emergency Medical Authorization
In the event of an emergency, I authorize Stand in For Nebraska and its designated agents, volunteers, camp staff, and authorized medical personnel to administer or to secure emergency treatment for my minor child. I understand that every effort will be made to contact me or the emergency contact listed prior to such action. I agree that I will be responsible for any and all medical services rendered. I further consent to the disclosure of necessary health information to camp personnel solely for the purposes of medical care, safety accommodations, and program administration. I have read and understand the above and affirm my authorization of emergency medical treatment for my child.
Parent/Guardian Signature for Medical Authorization
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
TRANSPORTATION SERVICES WAIVER AND RELEASE

Stand in for Nebraska, Roots to Rise program Transportation Services

Please read carefully. By signing below, you expressly assume the risks associated with transportation and waive claims against the organization.

I acknowledge that Stand in For Nebraska is not a common carrier and does not operate transportation services as a public utility. I further recognize the inherent risks of physical injury associated with transport in personal or rented vehicles, including but not limited to, boarding, exiting, and vehicle operations.

I voluntarily assume all risks, known and unknown, including those arising out of negligent acts or omissions by Stand in For Nebraska, its agents, officers, employees, or volunteers. I waive and relinquish any claims, causes of action, or liabilities that may arise in connection with the provision of transportation services to my minor child.

I give permission for my child(ren) to participate in Roots to Rise camp-related off-site field trips during the 2026 program, including educational trips to local farms, gardens, or similar community locations. I authorize transportation by Roots to Rise staff, volunteers, van, bus, chartered transportation, or other transportation arranged by the program. I understand that specific field trip details, including the date, destination, departure/return times, transportation method, and contact person, will be provided to parents/guardians before the trip. I understand that my child will not be required to attend a field trip if I notify Roots to Rise that I do not want my child to participate.

I further agree this waiver shall be governed by and construed under the laws of the State of Nebraska, and that any disputes arising shall be subject to the exclusive jurisdiction of the state and federal courts located in Lancaster County, Nebraska.

Participation in transportation services will be denied unless this waiver is signed.
Date

MonthDayYear
Transport Waiver Date
Parent/guardian Signature for Transportation Waiver

Transport Waiver Signature

WARNING OF RISK, WAIVER, AND RELEASE OF ALL CLAIMS

As parent(s) or guardian(s) of a participant in the Roots to Rise program, I/we understand that participation in camp activities involves inherent risks, including physical injury or property damage. I/we accept full responsibility for any injury, loss, or damage that may occur to my minor child as a result of their participation.

I/we hereby waive all claims against Stand in For Nebraska, its officials, officers, agents, employees, and volunteers, and against Northern Lighthouse Church, for any injuries, damages, or losses arising from or related to participation in Roots to Rise activities.

I/we agree to indemnify, defend, and hold harmless Stand in For Nebraska and Northern Lighthouse Church for any claims resulting from my child’s participation. I understand Stand in For Nebraska does not carry health or accident insurance for my child and that I am responsible for any medical costs incurred.

I understand that my child may be dismissed from the program for failure to follow rules or for conduct deemed disruptive, unsafe, or inconsistent with program values. I will work with staff as a partner to support my child’s successful participation.
Date

MonthDayYear
Date
Parent/Guardian Signature for Waiver and Release of Claims
MEDIA RELEASE PERMISSION GRANTED TO: STAND IN FOR NEBRASKA

I, the undersigned, grant permission to Stand in For Nebraska, its assigns and agents, to use my child’s name, image, voice, statements, or likeness in photographs, videos, or other promotional materials. This includes use in social media, newsletters, brochures, and websites.

I waive any rights to inspect or approve the final use of such media. I release Stand in For Nebraska, its directors, officers, employees, successors, and assigns from any and all claims, liabilities, or demands arising out of or related to such use.

I understand this consent may be revoked at any time in writing, effective prospectively from the date of notice.
Photo Release
Signature
Date

MonthDayYear
Date
I am able to pay $20 reservation fee to save spots for my child(ren).

Should be Empty:

Roots to Rise Registration

Youth Information

Reservation fee

Payment Methods