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Wild Roots Learning Center Registration Form 2024-2025
Please complete this form after you have signed our membership agreement, paid the membership fee, and enrolled in a program. Thank you!
Email *
Child's Name: *
Child's Date of Birth: *
Child's Gender: *
Child's Grade Level *
Child's Home Address: *
Parent 1 Full Name: *
Parent 1 Full Address (if different from child's):
Parent 1 Email Address: *
Parent 1 Mobile Phone: *
Parent 1 Home Phone:
Parent 1 Work Phone:
Parent 2 Full Name:
Parent 2 Full Address (if different from child's):
Parent 2 Email Address:
Parent 2 Mobile Phone:
Parent 2 Home Phone:
Please list 3 emergency contacts, their relationship to your child, and their phone numbers: *
Parent 2 Work Phone:
In the event of a medical emergency and neither you nor anyone on your emergency contact list can be reached, do we have permission to get medical attention for your child? *
If you answered no to medical treatment for your child in the event of an emergency, please indicate your preference for emergency treatment here.
Who has permission to pick up your child from our center? Please list full names and phone numbers. *
Does your child have any known allergies or health conditions? Please list and explain. If there are none, please type "none." *
Does your child have any food restrictions? If there are none, please type "none." *
Does your child have an IEP or 504 plan? *
Do we have permission to photograph or video your child during Wild Roots’ classes and events for use in our newsletter, newspaper, blog posts, social media platforms, and/or website, etc.? *
In which program are you registering your child? *
Is there anything additional you would like us to know about your child? *
Please indicate if you are available to serve as support staff at our center. Check as many as apply. *
Required
Please indicate that you have read and agree to the policies and guidelines in our information packet that was emailed to you. *
Required
Please read and agree to the following terms and conditions:

*Terms and Conditions: In order to enroll a child in our drop-off learning center or enrichment program, the parents must be General Members in good standing of Wild Roots PMA and must have signed a membership agreement and paid the membership fee. Program fees are due in full the first week of each month and may be paid via our website at www.wildrootspma.com, Venmo @wildrootspma, personal check, or cash.  Please note a service fee of 3% will be added to any payments made via website or Venmo. If payments are not received by the first week of each month, a 5% late charge will be applied. As per the Membership Agreement, Wild Roots reserves the right to terminate membership or this agreement “should they conclude that a specific member is interacting with them or any other members in a way that is contrary or detrimental to the focus, principles, and betterment of the Association” (Membership Agreement #7). *
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