Program Enrollment Form

Thank you for your interest in ROC ED.  Please use this form to register for our program.  You will receive a reply and confirmation within 24 hours of enrollment.

Child Information

Child's First Name (required)

Child's Last Name (required)

Child's Gender (required)
FemaleMale

Child's Date of birth (required)

Child's Age (required)

School Name (required)

Grade (required)

Teacher's Name

Please list any specific needs of your child.

Please list any known allergies of your child.

Please list all medications your child is taking.

Does your child have a public library card? (required)
YesNo


Program enrollment Information

Select your child's enrollment (required)

Will you need transportation? (required)

YesNo

What date do you need to start? (required)


Part-time schedule only - list the days service is need

Tell us about your child

My child's strengths are:

My child needs practice with:

My child enjoys:

What are your expectations for your child while participating in our program:

Parent/Guardian Information

First Name (required)

Last Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Preferred Phone Number (required)

Parent Email address (required)

Who does your child live with? (Please list names/relationships)

Emergency Contact

Name (required)

Phone Number (required)

Relationship to child (required)

Who is authorized to pick up your child?

Name (required)

Relationship to child (required)

Phone Number (required)

Name (required)

Relationship to child (required)

Phone Number (required)


Name (required)

Relationship to child (required)

Phone Number (required)

How did you hear about us? (required)

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