AMCH Interest Form
Date:
*
Today's Date:
Requested Date:
Schedule:
*
8AM-3PM
8AM-5PM
8AM-6PM
Meal Program (includes breakfast, freshly prepared lunch, and afternoon snacks)
Child's Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Current Age
*
Gender
*
Male
Female
Parent #1
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Format: (000) 000-0000.
Email Address
*
Parent #1 Employment Information
*
Employer
Job Title
Parent #2 Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Format: (000) 000-0000.
Email Address
*
Parent #2 Employment Information
*
Employer
Job Title
How did you hear about us?
*
Online Search
Yelp
Friends/Family Referral
Current AMCH Family
If referred, who can we thank?
Other:
Submit
Should be Empty: