Language
English (US)
Spanish (Latin America)
Russian
Roots Family Enrichment Program
How did you hear about Rebound/Roots?
*
Which Class Are You Wanting To Attend
*
Please Select
Bellingham Roots Each Thursday 4/25/24 to 5/30/24
Blaine Roots Each Monday 9/30/24 to 11/8/24
Do we have permission to take photo or video of you and your family for marketing purposes?
*
Yes
No
Annual Household Income
*
$0-$20,000
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000-$60,000
$60,000-$70,000
$70,000-$80,000
$80,000+
How many live in your household (including yourself)?
*
Please Select
1
2
3
4
5
6
7
8
9
10
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First Adult Attending Roots Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Preferred Method of Contact
*
Phone
Text
Email
Email
*
example@example.com
Gender
*
Woman
Man
Non-Binary/Gender Fluid
Prefer not to say
Pronouns
*
He/him/his
She/her/hers
They/them/theirs
Other
Primary Language Used in Your Household
*
English
Spanish
Other
Race (check all that apply)
*
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are you Hispanic or Latino?
*
Yes
No
Marital Status
*
Single
Married
Divorced
Widowed
Do you have any allergies?
*
What is your relation to the children listed below?
*
Emergency Contact Person (other than self)
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Who is authorized to pick up your child in the event of an emergency?
*
Please indicate which, if any, of the following services you are currently receiving:
*
Apple Health/Medicare
Woman, Infants, and Children Program (WIC)
Food Stamps/EBT
Washington State Housing Assistance
I am not receiving any of these services
(Optional) Are you currently impact by any of the following?
Houselessness/Unstable housing
Mental illness
Domestic violence
Child(ren) in foster care/in care of others
Substance dependence
(Optional) Growing up, did you experience any of the following?
Teen pregnancy
Being raised by someone in the armed forces
Being raised by a single parent
Foster care/being raised by someone other than your biological parents
Sexual abuse
Experimentation with drugs and/or alcohol
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Next
Second Adult Attending Roots Information
Please leave blank if only first adult is attending.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Method of Contact
Phone
Text
Email
Gender
Man
Woman
Non-Binary/Gender Fluid
Prefer not to say
Pronouns
He/him/his
She/her/hers
They/them/theirs
Other
Primary Language Used in Your Household
English
Spanish
Other
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are you Hispanic or Latino?
Yes
No
Marital Status
Single
Married
Divorced
Widowed
Do you have any allergies?
What is your relation to the children listed below?
Please indicate which, if any, of the following services you are currently receiving:
Apple Health/Medicare
Woman, Infants, and Children Program (WIC)
Food Stamps/EBT
Washington State Housing Assistance
I am not receiving any of these services
(Optional) Are you currently impact by any of the following?
Houselessness/Unstable housing
Mental illness
Domestic violence
Child(ren) in foster care/in care of others
Substance dependence
(Optional) Growing up, did you experience any of the following?
Teen pregnancy
Being raised by someone in the armed forces
Being raised by a single parent
Foster care/being raised by someone other than your biological parents
Sexual abuse
Experimentation with drugs and/or alcohol
Back
Next
First Child Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
*
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
*
Yes
No
What grade are they in?
*
Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Are they attending Roots?
*
Yes
No
I'm not sure yet
Do they have any allergies?
*
Back
Next
Second Child Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
Yes
No
What grade are they in?
Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Are they attending Roots?
Yes
No
I'm not sure yet
Do they have any allergies?
Back
Next
Third Child Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
Yes
No
What grade are they in?
Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Are they attending Roots?
Yes
No
I'm not sure yet
Do they have any allergies?
Back
Next
Fourth Child Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
Yes
No
What grade are they in?
Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Are they attending Roots?
Yes
No
I'm not sure yet
Do they have any allergies?
Back
Next
Fifth Child Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
Yes
No
What grade are they in?
Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Are they attending Roots?
Yes
No
I'm not sure yet
Do they have any allergies?
Submit
Should be Empty: