Registration Application

To register a client to participate in our programs, click on the button below. Please note we do have a waitlist. To be placed on our waitlist you must register first. Thank you kindly,
  • MM slash DD slash YYYY
  • Client Information

  • MM slash DD slash YYYY
  • Guardian Information One (1)

  • Guardian Information Two (2)

  • Emergency Contact Information (other than legal guardian)

  • Emergency Contact One (1)

  • Emergency Contact Two (2)

  • List Individuals authorized to pick up client

  • Medical Information

  • Medication

    Please note - if medication is required during Program hours the caregiver is responsible for administering.
  • Family Physician

  • Client Profile

  • Please List Any Assistive Devices the client uses daily (walker, wheelchair, cane, glasses, hearing aids, etc.)
    Please select all that apply.
    Please select all that apply.
  • Client's Life Skills

  • Communication, Behaviour, and Personality

  • Strengths, Needs, and Goals

  • Registration Agreement

    Please confirm that the information you provided to Roots 2 Wings is complete, current, and accurate. You are also permitting the client, as their legal guardian or caregiver to participate in all the program activities at Roots 2 Wings. Roots 2 Wings provides a safe and caring learning and social environment that the client participates in with their caregiver’s permission at their own liability. In the event of an accident or illness affecting the named client, I give Roots 2 Wings staff permission to authorize on my behalf to bring the client to receive medical attention. Such action will only be taken when immediate contact with the undersigned caregiver/legal guardian or their designate cannot be made within a timely manner. The undersigned also gives permission to Roots 2 Wings to use photographs while at the Program for the purpose of promotional and programming purposes. I have read and understand the Roots 2 Wings Program Handbook regarding fee schedules, policies and payment obligations.