* Indicates required question

    Parent Name *

    Parent Cell Phone Number *

    Email *

    Home Address *

    Student Name *

    Gender *
    Check all that apply.

    Student Birthday (Example: January 7, 2019) *

    Student Age *

    Emergency Contact 1 (First/Last Name, Relationship, Phone Number) *

    Emergency Contact 2 (First/Last Name, Relationship, Phone Number) *

    Authorized Pick-Up (First/Last Name, Relationship, Phone Number) *

    Which Program? *
    Check all that apply.

    What is your child's grade level? *

    Health Information? Include Dietary Restrictions and Allergies *

    I understand that I will have to pay a one time $50 registration fee. *

    I understand that I will have to pay the grade specific curriculum and material fee via check. *

    I have read over the Rooted in Faith Handbook and will return the signed agreement with my payment. *