MMS On Wheels Form

Parent/Guardian Name*

PrefixFirst NameLast NameSuffix

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Validator*

ID Upload*

Browse Files

Please upload a copy of your ID

Cell Phone*

Area CodePhone Number

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Other Phone

Area CodePhone Number

Emergency Contacts (You May Add As Many As You Need)

Child's Name*

PrefixFirst NameLast NameSuffix

Child's Date of Birth*

MonthDayYear

Grade Level During 2025 - 2026 School Year*

What grade is your child in during the 2024-2025 school year?

Please tell us about your child's allergies and health condition.*

Transportation Options:

Drop off - You bring your child(ren) to our facility, we make sure they get to school on time and safely.
Pick up - We pick your child(ren) up from school and bring them to our facility.

(Monday - Friday)

Name Of The School Child Attends*

School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pick Up From SchoolPick Up AND Drop OffDrop Off At SchoolI don't need transportation for Monday

Pick Up From SchoolPick Up AND Drop OffDrop Off At SchoolI don't need transportation for Tuesday

Pick Up From SchoolPick Up AND Drop OffDrop Off At SchoolI don't need transportation for Wednesday

Pick Up From SchoolPick Up AND Drop OffDrop Off At SchoolI don't need transportation for Thursday

Pick Up From SchoolPick Up AND Drop OffDrop Off At SchoolI don't need transportation for Friday

Select Start Date For Pick up*

MonthDayYear

When Is The Earliest Time Your Child Can Be Picked Up From School?*

:HourMinutesAM/PM Option

When Is The Latest Time Your Child Can Be Picked Up From School?*

:HourMinutesAM/PM Option

Select Start Date For Drop off*

MonthDayYear

When Is The Earliest Time Your Child Can Be Dropped Off At School?*

:HourMinutesAM/PM Option

When Is The Latest Time Your Child Can Be Dropped Off At School?*

:HourMinutesAM/PM Option

Auto Pay Notes

Math Made Simple offers Auto Pay.
If you're interested in auto pay, there is a form that must be filled out and returned to us.
If you decide to use Auto-Pay, we'll give you a copy of the form that needs to be filled out the first day you arrive.
We run payments every Monday excluding weeks when we're closed.
You may opt out at any time.
If you opt out in the middle of the week, a payment will still be debited from your method of payment unless you contact us before the upcoming Monday at 10:00 AM.
If you are on auto pay and wish for a payment not to be taken out for a particular week, we must be notified before the Monday that the payment is due to be debited before 10:00 AM
If the transaction is unsuccessful, the client will be removed and will not be able to return until payment is received.

YesNo

Total Amount Due Each Week For Transportation (In Dollars)

How did you hear about us?*

Please leave any additional notes, comments, or questions here.

We're located at:

Math Made Simple, Etc.
7189 Stage Road
Memphis, TN 38133

For more information please contact:

Cornelius Barnes

corneliusbarnes.mms1@yahoo.com
www.mathmsimple.com
Office: 901-382-3244
Cell: 901-326-6475

or

Alexie Akah II

aakah2@mathmsimple.com
Office: 901-382-3244

Notice About Payments:

First week's payment and registration are due at sign up to reserve your child's seat.
Registration is $127 and paid once per school year.
Payments are due every week that Math Made Simple is open regardless of if services are rendered or not.
Fees can change at anytime without notice.
If a student is out for an entire week from when services began, the payment collected for that week will be applied to the last payment of the agreement.
A late fee of 15% of the weekly rate will be added to each payment that is more than two (2) days late.
For example: If your weekly rate is $60 per week, and you do not make your payment by end of business on Wednesday of that week, $60 plus an additional $9 ($60 per week * 15%) will be due before you can continue utilizing our transportation services.
This agreement is between you and Math Made Simple and last for a semester.
If you must stop for whatever reason before the end of the semester cycle, 2 weekly payments are due.
For example: If you choose the Pick Up ($60 per week) option, and only complete half of the semester agreement, $120 ($60 per week x 2) is due to satisfy the agreement.

I have read and understand everything on this form, and my information is correct to the best of my knowledge

Parent/Guardian Signature (You may use a mouse or a stylus/your finger (for touchscreens)*

Total Deposit Due (In Dollars)