SIBLING ENROLLMENT FORM

To place a sibling of a currently enrolled child on the Wait List, please:

Submit the form below
Mail a check in the amount of $40 to the ChildRoots Main Office, Attn: Wait List, 1712 E Burnside St. Portland, OR 97214.

Once we confirm receipt of both, we will send you an email confirmation.

Preferred Location(s) *

Fremont Center

Northwest Center

Southeast Center

Preferred Schedule *

2 days: Tu, Th

3 days: M, W, F

5 days: M-F

Flexible (whatever's available)

Preferred Start Date *

Preferred Start Date

YYYY

CHILD INFORMATION

Child DOB *

Child DOB

YYYY

Name *

Name

First Name

Last Name

Sibling Name *

Sibling Name

Name of currently enrolled child

First Name

Last Name

PARENT CONTACT INFO

Parent Name *

Parent Name

First Name

Last Name

Phone *

Phone

(###)

###

####

Email *

Would you like to share anything with us?