Student Enrollment Registration Form for Busy Bee Academy

STUDENT APPLICATION FORM

An application fee of $100(non-refundable) per child must be submitted to the Busy Bee Academy office before enrollment can occur. This application fee will also hold an enrollment spot in the event there is a wait list in your desired program. Cash and checks payable to BUSY BEE ACADEMY are accepted as well as electronic ACH via the link on provided invoice. Once this application is submitted, Busy Bee Academy will follow up with an application invoice to be paid in full to meet the requirements stated above.
Parent/Guardian Information

(Please enter all information though it is not required)
Name*

First NameLast Name
Name

First NameLast Name
Relationship to Student*
Relationship to Student
e-mail*
example@example.com
e-mail
example@example.com
Employer
Employer
Primary Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Data Information

(Please enter all information though it is not required)
Program *
Please choose desired Enrollment Program from drop down
Days Attending*
Part time enrollment must be MWF or TTH only
Desired Enrollment Date*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Student Name*

First NameLast Name
Nickname
Date of Birth*

MonthDayYear
Gender*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relegion
(Optional)
Nationality
(Optional)
Sibling 1

First NameLast Name
Sibling 1

MonthDayYear
Date of birth
Sibling 2

First NameLast Name
Sibling 2

MonthDayYear
Date of birth
Emergency Contact Information

Please list two contacts in an emergency if parent(s)cannot be contacted. (Please enter all information though it is not required)
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital Preference*
Allergies*
Please enter N/A if none apply
Physician Information

(Please enter all information though it is not required)
Office Name
Physician Name

First NameLast Name
Physician Phone Number

Area CodePhone Number
Release Authorizations

The following person(s) have my permission to pick up my child(ren) in the event I am unable to do so. (Please enter all information though it is not required)
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation
Name
Phone Number

Area CodePhone Number
Relation
Name

First NameLast Name
Special Pickup Information

The following person(s) is/are restricted by court from picking up your child unless specific authorization has been granted. Please submit legal documents to office llo in order for us to enforce this authorization. (Please enter all information though it is not required)
Relation
Name

First NameLast Name
Relation
Name

First NameLast Name
Relation
Insurance no Information

(Please enter all information though it is not required)
Insurance Company
ID #
Policy Holder
Group #
List any special needs that your child may have, such as allergies, existing illness(es) (asthma, diabetes, etc) previous serious illness(es)impairments and or injuries during the past twelve months, any medications prescribed for long term continuous use, and any other information which staff should be aware of.*
Enter N/A if none apply
Photo Release
Busy Bee Academy MAY or MAY NOT (choose from drop down below) photograph my child during class for display in their classroom or school photos. *
PLEASE INITIAL FOR PHOTO RELEASE CHOICE INDICATED ABOVE*
Social Media Photo Release
Busy Bee Academy MAY or MAY NOT (choose from drop down below) be granted the permission to use your child(ren)'s photograph for likeness in all forms and media for advertising, demo, editorial, trade, altering without restrictions and all other lawful purposes. I understand and agree that neither I nor my child(ren) will be entitled to any compensation. I release Busy Bee Academy from all forms of claims and liability related to my child(ren)'s photo usage.*
PLEASE INITIAL FOR SOCIAL PHOTO RELEASE CHOICE INDICATED ABOVE*
Additional Parent Comments and Information - Is there any information that would be helpful to our management and teaching staff?*
Enter N/A if none apply
Terms and Conditions
I understand and acknowledge that by checking the box below, I am legally agreeing to all of the statements and information I have provided in this document to be true and correct to the best of my knowldege and belief.

ALL PARENTS/GUARDIANS OF MINORS MUST READ THIS DOCUMENT CAREFULLY BEFORE AGREEMENT. THIS DOCUMENT/AGREEMENT/CONTRACT HAS LEGALLY
BINDING CONSEQUENCES AND WILL AFFECT YOUR LEGAL RIGHTS AND WILL LIMIT YOUR AND ANYONE WHO YOU REGISTER, ABILITY TO BRING FUTURE LEGAL ACTIONS.
REQUIRED*

I Agree
A registration fee of $100(non-refundable) per child must be submitted to the Busy Bee Academy office before enrollment can occur. This registration fee will also hold an enrollment spot in the event there is a wait list in your desired program. Cash and checks payable to BUSY BEE ACADEMY are accepted. All major credit cards are accepted (transaction fee may apply).
Should be Empty:

STUDENT APPLICATION FORM

Parent/Guardian Information

Child Data Information

Emergency Contact Information

Physician Information

Release Authorizations

Special Pickup Information

Insurance no Information

Photo Release

Social Media Photo Release

Terms and Conditions