Board of Directors Application

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ABOUT US
- Board of Directors
- News + Updates
PROGRAMS
EVENTS
GET INVOLVED
CONTACT

Which service(s) are you interested in?*

Early Intervention | Utah and Arizona areas (developmental delay, birth - 3 years old)

Kindermusik | Washington County

Early Head Start Home-Based | Washington County (prenatal - 3 years old)

Parents as Teachers | Washington and Iron Counties (home-based, prenatal - 5 years old)

Caterpillar Clubhouse Childcare | St. George (6 weeks - 3 years old)

Family Support Coordination | Arizona Only

Early Head Start Center Based | Hildale (12 - 36 months)

Unsure

Child's Full Legal Name*

If applying for a pregnant mother please put N/A

Child's Gender*

Child's Birthday (MM/DD/YYYY)*

If applying for a pregnant mother please put due date.

Parent/Guardian Name*

Parent/Guardian's Birthdate (MM/DD/YYYY)

Primary Home Language*

Phone Number*

If you do not currently have a phone number please put N/A

E-mail Address*

If you do not currently have an e-mail address please put N/A

Preferred Method of Contact*

Street Address*

Address Line 2 (Apartment Number, Suite, etc.)

City*

State*

Zip Code*

Who is completing this form?

Parent, Physician's Office, Staff Name, etc.

Do you have any concerns about...*

Motor Skills (rolling, crawling, sitting, walking, etc.)

Vision

Hearing

Communication

Behavior

Problem-Solving

Feeding

Sleeping

Health/Diagnosed Condition

No Developmental Concerns

Other

Is there anything else you would like us to know about the child's health and development? *

How did you hear about Root for Kids?*

Please specify (organization, name of physician, community event name, social media platform, school name, etc.)*

2044 S Mesa Palms Drive

St. George, UT 84770

435-673-5353

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