WILD ROOTS FOREST KINDERGARTEN & PRESCHOOL

Meeting the World with Wonder

Wild Roots Application

2011-2012
6163 Stow Canyon Road, Goleta Ca l i f o r n ia 93117

(805)570-3087

A non-refundable fee of $75.00 is due with the completed application.

Students
Name:___________________________________Birthdate:_______________Sex:___
_
Applying for (please check one)
Willows:____
Acorns ____
1 day per week___ 2 days per week___
PARENT/ GUARDIAN #1:
Name:
_____________________________________________________________________
Home Phone: _______________________ Work Phone: _______________________
Cell Phone____________________________
Address:_______________________________________________________________
City, State, ZIP:_________________________________________________________
E-mail_________________________________________________________________
Occupation and Employer:________________________________________________

PARENT/ GUARDIAN #2:

Name:________________________________________________________________
Home Phone: _______________________Work Phone: ________________________
Cell Phone __________________________
Address:_______________________________________________________________
City, State, ZIP:_________________________________________________________
E-mail:__________________________________________
Occupation and Employer:________________________________________________

WILD ROOTS FOREST KINDERGARTEN & PRESCHOOL

Meeting the World with Wonder

Wild Roots Application

2011-2012
6163 Stow Canyon Road, Goleta Ca l i f o r n ia 93117

(805)570-3087

Is student transferring from another school? Y/N

If yes, which one?____________________________________________________
Why?_________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please tell us who else lives in the house with you (i.e. brothers, sisters,
grandparents, friends, etc):
Name:
Age:
Relationship:
______________________________ ________ ___________________________
______________________________ ________ ___________________________
______________________________ ________ __________________________
______________________________ ________ __________________________
Please describe the child's living situation and home life (if child spends time at
more than one home tell us about both:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
List the capacities, gifts, and talents of your child. Describe the activities, events
and items in which your child shows passion and curiosity. Feel free to use a separate
sheet of paper.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

WILD ROOTS FOREST KINDERGARTEN & PRESCHOOL

Meeting the World with Wonder

Wild Roots Application

2011-2012
6163 Stow Canyon Road, Goleta Ca l i f o r n ia 93117

(805)570-3087

______________________________________________________________________
______________________________________________________________________
What areas do you feel your child might need assistance in?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What kinds of activities and interests is your child encouraged to engage in?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
How would you describe your child? Please address the following areas: social,
emotional, physical, cognitive, any fears he or she may have, special interests,
sensitivities, and anything else you would like us to know:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

WILD ROOTS FOREST KINDERGARTEN & PRESCHOOL

Meeting the World with Wonder

Wild Roots Application

2011-2012
6163 Stow Canyon Road, Goleta Ca l i f o r n ia 93117

(805)570-3087

What are you hoping to find in this education for your child?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Medical History:
* Please list any necessary medical needs your child might have:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
*Does your child take medication?_______If so, what kind and at what dosage?
______________________________________________________________________
______________________________________________________________________
How long has your child been on this medication?
________________________________________
Comments:____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Any childhood illnesses? (i.e. chicken pox, whooping cough, etc.)__________
Please name type, severity, duration (approximate), and age of onset:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

WILD ROOTS FOREST KINDERGARTEN & PRESCHOOL

Meeting the World with Wonder

Wild Roots Application

2011-2012
6163 Stow Canyon Road, Goleta Ca l i f o r n ia 93117

(805)570-3087

Please list any allergies (food, environmental, medicines, insects, etc.), as well as
frequency, severity and treatment:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Does your child have a history of ear infections?______
Is there anything else you would like us to know?_______________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Do we have your permission to contact your childs previous teacher/caregiver?______
If yes, please provide name, phone number and address:________________________
______________________________________________________________________
______________________________________________________________________
Parent/Guardian signature _________________________________Date ___________
Parent/Guardian signature _________________________________Date ___________
STATEMENT OF NON-DISCRIMINATORY POLICY: Wild Roots does not discriminate
on the basis of race, religion, or national origin in its admission policy or conduct of its
educational programs.
FOR OFFICE USE ONLY:
Date Received:

Acknowledgment date:

Initials: