Online Application

ROOTS ACTIVIY LEARNING CENTER
ADMISSIONS APPLICATION

Proposed Entry Date

Curent Grade

Infant Centerr:

Toddler

Pre-K3 -Pre-K4

Student's First Name

Student's Last Name

Student's Middle Name

Age

Date of Birth

Child Lives with:

Physician's Name

Phone Number

Street Address

City

Postal / Zip code

Thank you! We will contact you within 5 working days.

Parent/Guardian # 1 Information

Guardian's Name

Last 5 of SS Number

Guardian's Address

City

Postal / Zip code

Main Phone (Home)

Work Phone

Cell Phone

Occupation

Street Address

City

Postal / Zip code

Employer

Relatinship of Relative or Other

Parent/Guardian # 2 Information

Last 5 of SS Number

Guardian's Address

City

Postal / Zip code

Main Phone (Home)

Work Phone

Cell Phone

Occupation

Employer

Street Address

City

Postal / Zip code

Relatinship of Relative or Other

Guardian's Name

Your Signature

Select a date

Please Note: In a case of emergency the Administration will contact the mother, father, or Legal Guardian; if neither can be reached, the first person on the Authorized Emergency List will be contacted.

Although you have signed this form online, we require the legal guardian's official signature before your child can be enrolled.

ROOTS ACTIVIY LEARNING CENTER ADMISSIONS APPLICATION

Parent/Guardian # 1 Information

Parent/Guardian # 2 Information

ROOTS ACTIVIY LEARNING CENTER
ADMISSIONS APPLICATION