Summer Program Application with Sliding Fee Scale Application
Registration for Deep Root Center's Summer Program - this form includes: emergency Info, release form, and the DRC Community Agreement. *You will need medical insurance information to complete this form, as well as income information.
Sliding Scale fees are indicated on the chart below. Please complete the Sliding Scale application (below), if you require a fee reduction. Full Fee Payment Options for M-F 8:30-3:30: 1 child - $175/week or $37/day, 2 children - $320/week or $65/day, 3 children - $445/week or $90/day *Additional option:$15/afternoon for extended day 3:30-5:15 * Checks can be made out to Deep Root Center, or you can pay through PayPal on the Deep Root Center Website. * PayPal payments incur an additional $5 fee/transaction.
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Name(s) and Age(s) of Child(ren) attending
Planned Use of Program
Regular Hours: Monday - Friday: 8:30–3:30 Extended Hours: 3:30-5:15 - If you will be utilizing the drop-in program, please let us know which days your child will be here during the week.
Will you be utilizing the Drop-in Option
If so, how many days, on average, each week?
Will you be utilizing the extended hours (3:30 -5:15)
Please list any health concerns including medications, allergies, etc. Answer N/A if there are none.
Please indicate any non-custodial person(s) who is legally restricted from having contact with your child(ren) with a brief explanation:
Alternate Person to Contact in Case of Emergency (non-parental), their relationship to your child, and their Phone Number.
Physician's Name or Healthcare Group with Phone Number
Mental Health Counselor with Phone Number
Insurance with ID Number
Please add anything you think we should know about your child.
Release - In consideration of my participation and the participation of my child in the activities of Deep Root Center for Self-Directed Learning, I hereby release DRC from any and all liability for injuries or loss which I or my minor child may incur as a result of said activities for so long as I or my child participate in said activities.I hereby acknowledge that some activities may involve working with potentially dangerous materials or traveling. However, I fully accept these risks for me and my child and agree to hold harmless and free from any and all liability DRC, its governors, officers, directors, volunteers, and employees for injuries which may be incurred while engaged in said activities. From time to time we take pictures during DRC's daily activities. We often use these pictures on our website, social media, blog, or in other promotional materials. We will never reference your child by full name (first name only) or provide any specific information regarding your child. We also will never sell these pictures; we will use them exclusively for DRC’s purpose. I have read and I understand the entirety of this participation form and accept all of its provisions.
Community Agreement - Respect Yourself, Everyone Here, and this Place
We want Deep Root Center for Self-Directed Learning to be pleasant for everyone who enters. DRC welcomes a constant stream of visitors of all ages. We appreciate playing, laughter, and socializing in a public setting. We do not tolerate bullying, inappropriate language, destruction of property, or other hostile behavior. DRC aims to be clean and attractive - All members of the community are expected to clean up their own trash and contribute to the general attractiveness of the space. Within reasonable limits, DRC staff may request help from any student at any time to tidy up our space. We are all responsible for the creation of a desirable community. Everyone helps. Thank You! Community Contract- I have read the above, and understand that if my behavior is harmful to myself and/or is an ongoing low-level grievance, I will be asked to meet with the DRC staff and my parent(s) or guardian(s) to mediate an action plan to ensure my success at DRC..
The Sliding Fee Application is Below
If you plan on paying full fee, scroll down to the bottom and click the submit button. Otherwise, please complete the following questions. Thank you!
Please list sources of household income (including: salary, hourly wage, SSI, child support, disability, etc.) We ask that you submit pay stubs or other proof of income with SS# crossed out.
Please indicate monthly gross income
Please indicate annual gross income
Please indicate the number of people in your household
We will be in touch within 24 hours to finalize your application, which will include your fee from the chart above. We look forward to meeting you and your child(ren).
Should be Empty: