Rooted Stories Family Literacy Program Application

Rooted Stories Family Literacy Program Application

Share your family and child details, cohort preferences, and any support needs to apply for the program.
Parent/Caregiver Information
Parent/Caregiver Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City / ZIP Code
Preferred Language

Other
Child Information
Child Information
Older Siblings
Will any older siblings attend with your family?
If yes, please list the older siblings' names and ages
Accessibility & Family Needs
Sensory supports needed

Other
Translation or interpretation needed

Other
Dietary accommodations needed

Other
Mobility accommodations needed

Other
If other, please describe additional family needs
About Your Family
How often does your family currently read together?
What do you hope your family will gain from participating in Rooted Stories?
How did you hear about Rooted Stories?

Other
Please rank the Rooted Stories groups in order of preference (1 = Most Preferred).

We will do our best to place your family in your highest-ranked group. Placement is based on availability, and your first choice cannot be guaranteed.
Participation Agreement
Ranking
I agree that a caregiver will attend every session with my Kindergarten–2nd grade child
I understand the program meets twice each week for four weeks, for a total of 8 sessions
I understand our family will receive free meals, books, literacy materials, a Rooted Stories Family Library Bag, and a free field trip
I understand transportation assistance is available if needed
I agree to notify One Root Collective as soon as possible if we are unable to attend a session
I understand that my child and/or family may be photographed or recorded during the Rooted Stories program and give One Root Collective permission to use these images/videos for promotional, educational, grant reporting, and fundraising purposes.
Parent/Caregiver Signature
Date

MonthDayYear
Date
Should be Empty:

Rooted Stories Family Literacy Program Application

Parent/Caregiver Information

Child Information

Older Siblings

Accessibility & Family Needs

About Your Family

Please rank the Rooted Stories groups in order of preference (1 = Most Preferred).

Participation Agreement