AMSS Bumble Bee Program

AMSS Bumble Bee Program
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Age 0-4 Programs Registration
Expected Start Date

MonthDayYear
Date
Expected Departure Date

MonthDayYear
Date
Which class are you wanting to register for?
Student Information
Name

First NameLast Name
Gender
Birth Date

MonthDayYear
Date
Home Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Care #
Doctors Name

First NameLast Name
Doctors Phone Number
Format: (000) 000-0000.
Parent/Guardian Information 1
Full Name

First NameLast Name
Home
Format: (000) 000-0000.
Cell
Format: (000) 000-0000.
Work
Format: (000) 000-0000.
E-mail
example@example.com
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home
Format: (000) 000-0000.
Cell
Format: (000) 000-0000.
Work
Format: (000) 000-0000.
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Infomation
Would you like to be a part of our literacy program and receive information and resources available to you and your child?
If yes, name and age of friend(s)?
Is your child immunized?
Does your child have any allergies?
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?
Please list the people authorized to pick up your child.
Does your child have any siblings?
If yes, what is their age(s)?
Comments
If yes, which one?
Emergency Contact - Other than Parent/Guardian
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home
Format: (000) 000-0000.
Cell
Format: (000) 000-0000.
Work
Format: (000) 000-0000.
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Should be Empty:

AMSS Bumble Bee Program

Age 0-4 Programs Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian