Application - English - Root for Kids

Parents Name(s)*

Child's Name

First Last

Child DOB

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home/Cell Phone

(primary phone)

Work Phone

Email

Prefered Method of Contact

(home phone, work phone, email)

Schedule

5 Days (Monday-Friday)
3 Days (M, W, F)
2 Days (T, Th)

Special Instructions of Information

Please provide any important information about your child and family that would be helpful for us to know including schedule, allergies, medications, and/or medical needs.

Child Strengths and Goals

What are your child’s strengths? What are your concerns with your child’s development if any? What goals would you like your child to be working toward?

Documents and Fees that will be due at time of enrollment: - $35.00 Application Fee - Current copy of immunizations/immunization exemption letter - First Tuition Payment - Subsidy information, if eligible/applicable - Child Admission Agreement

Immunizations

Max. file size: 16 MB.

Please upload a current copy or an immunization exemption letter, if applicable

Print Your Name

Signature

CAPTCHA

Email

This field is for validation purposes and should be left unchanged.