Rooted Village Registration 2023/2024
Welcome to Rooted Village! Once your application is submitted, we will send you an invoice for registration, a code of conduct form and waiver. An assessment will also be scheduled for those children taking part in our curriculum learning. Finally, we will get you set up in our backend system called HiMama! 
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Please Select your Co-op Home *
Child Name (First, Last)  *
Date of Birth  *
MM
/
DD
/
YYYY
Allergies (Please write NKA if there are no allergies)  *
Physician Name 
Physician Phone Number 
Chronic Medical Conditions (Please explain) 
Parent/Guardian #1 Name  *
Parent/Guardian #1 Phone Number  *
Parent/Guardian #1 Email Address  *
Parent/Guardian #2 Name 
Parent/Guardian #2 Phone Number 
Parent Guardian #2 Email Address 
Emergency Contact Name, Phone, Relationship  *
Anything you'd Like us to Know About your Child? 
 Any medical diagnosis that directly affects learning (ASD, ADHD, Hard of Hearing/ Sight Anxiety, etc.) should be listed here. - A copy of 504 or IEP plans should be provided prior to the start of the homeschool season. This will allow us to better accommodate the child’s needs and ensure safety and success.  
Please Choose Which Day/s You'll Attend  *
Required
If You are Attending Individual Classes Only, Please list which class/es 
Please List any Siblings Attending 
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