Simply Rooted Application For Enrollment

Registration Requirements, Discount and Information

In order to enroll and have your child attend our Farm School, your Simply Rooted membership must be in good standing and all financial commitments must remain current throughout the school year. Payments made to Chris or Kallie Avey by check are due monthly on the 5th. Cash, Venmo and Cash App payments may also be accepted if needed.

An additional $100 added to the tuition is non-refundable and must accompany this application. Your $100 deposit will hold space in our school for your child(ren) along with assisting in their educational supplies. This $100 fee will be per semester billed now and January. Private Pay Tuition is due monthly but may be paid annually at a discount rate.

Pricing

Pricing is listed as monthly fee.
(Monday, Wednesday, Thursday)

8:00am-3:30pm

Ages 3year-5year $500 (must be potty trained)

Grade K: $500
Grade 1-4: $500
If you have a child grades 5-12 who would like to attend please send us an inquiry at simplyrootedlearning@gmail.com or message our Facebook page Simply Rooted.
Required fields

Parent/Guardian Information
1st Parent/Guardian Name

First NameLast Name
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
example@example.com
2nd Parent/Guardian Name

First NameLast Name
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
example@example.com
Are you new to Simply Rooted this year?

Information for Child 1
Name of Student 1

First NameMiddle NameLast Name
Grade in this School Year
Birth Date

MonthDayYear
Gender:
Nickname name (preferred)
Previous school education (school and dates):
Medical Needs for Child 1
Does your child have any medical/emotional problems of which we should be aware?
Please explain your child's medical/emotional needs here
Does your child have any allergies?
Please describe your child's allergies here
Is your child on any regular medication? Please note we do not administer medication at Simply Rooted.
Please list your child's regular medications here.
Does your child receive extra help outside the classroom at his/her secular school? (i.e. IEP, speech therapy, reading resource, etc.)?
Please explain the type of help he/her receives here.
Add another child?

Information for Child 2
Name of Student 2

First NameMiddle NameLast Name
Grade
Birth Date

MonthDayYear
Gender:
If student is 8th-12 grade, please provide their e-mail and cell phone:
Medical Needs for Child 2
Does your child have any medical/emotional problems of which we should be aware?
Please explain your child's medical/emotional needs here
Does your child have any allergies?
Please describe your child's allergies here
Is your child on any regular medication?
Please list your child's regular medications here.
Does your child receive extra help outside the classroom at his/her secular school? (i.e. IEP, speech therapy, reading resource, etc.)?
Please explain the type of help he/her receives here.

Emergency Contact
Contact Name

First NameMiddle NameLast Name
Phone Number
Relationship to student
Additional Emergency Contacts and Phone Numbers
Who can pick my child up from school? Please note all pick up personnel MUST have ID and be in the list below.

Grade selection and Payment Details
NOTE:
Only PART TIME option is available at this time.
prevnext( X )
$100 Deposit and Supply Fee
$100.00 Quantity

First Month Payment
Part Time

$500.00 Quantity

Total

$0.00
Payment Details
Would you like to pay by Check or App?
PAYING BY CHECK

Your application will not be final until we receive the minimum non-refundable deposit of $100. Payments by check are only accepted for paying the deposit or paying the tuition in full.

Make all checks payable to "Kallie Avey" and mail to:

Simply Rooted
314 Round Mountain Road
Alco, AR 72680
Payment Options
Please choose how you would like your payment to be spread:
YOU CAN HELP OTHERS
ADDITIONAL COMMENTS/CLASS PLACEMENT REQUESTS
Do you have any additional comments you would like to make about your Registration Application?

EMERGENCY & MEDICAL INFORMATION
Occasionally an emergency arises when it is necessary for a School representative to contact parents when their children are at school. Every effort will be made to notify the parents or someone designated by them if a child should become very ill or be involved in an accident. If this cannot be done, the policy of the Farm School is to transport the child to the nearest emergency hospital. This action will be taken in all such cases unless instructions to the contrary are provided by the parents.

(We), the undersigned, parents/guardian of a minor(s), do hereby authorize Simply Rooted (Kallie Avey or future employees) as agent for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Arkansas Medicine Practice on the medical staff of a hospital, whether such examination, diagnosis or treatment is rendered at the office of said physician or at such a hospital.

It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment or hospital care being required and is given to provide authority and power on the part of our above-named agent to give specific consent to any and all such examinations, diagnoses, treatment or hospital care which the aforementioned physician in the exercise of his/her judgment may deem advisable.
Name of Neighbor/Friend
Phone Number of Neighbor/Friend
Name of Relative
Phone Number of Relative
Doctor/Medical Group Name
Phone Number of Doctor/Medical Group
Insurance Company Name
Phone Number of Insurance Company
Please check "Yes" or "No" to provide your consent.
PERMISSION SLIP
I hereby grant permission for my child/children to participate in Simply Rooted Farm School activities and events and to release Simply Rooted and its representatives from all liability arising out of my child's participation.

Please check "Yes" or "No" to provide your consent.
Required field
MEDIA ACKNOWLEDGMENT
I further grant permission for Simply Rooted to use my child’s image and voice in printed & electronic materials, with the knowledge that no last names will be used on a public document.

Please check "Yes" or "No" to provide your consent.
Required field
Authorize your consent by typing the name of one parent or guardian here:
Click to edit
Should be Empty:

Registration Requirements, Discount and Information

Pricing

Parent/Guardian Information

Information for Child 1

Medical Needs for Child 1

Information for Child 2

Medical Needs for Child 2

Emergency Contact

Grade selection and Payment Details

*

Payment Details

Payment Options

YOU CAN HELP OTHERS

ADDITIONAL COMMENTS/CLASS PLACEMENT REQUESTS

EMERGENCY & MEDICAL INFORMATION

PERMISSION SLIP

MEDIA ACKNOWLEDGMENT