PLEASE COPY, PASTE, PRINT AND MAIL THIS FORM 

                                  A. M. A. Family Daycare

                                                        Registration Form

Today’s Date: ______/______/_______                               WAITING LIST #

Child’s First Name:

Child’s Middle Name:

Child’s Last Name:

Any Nicknames:

Date of Birth:

________/__________/________

START DATE: (A.M.A FILLS IN THIS DATE ONLY)

______/________/_________

Names of Siblings enrolled with A. M. A:

Date of Birth of Siblings:

{1} Parent/ Guardian’s First Name:

Parent/ Guardian’s Last Name:

Relationship to Child:

Street Address:

City, State and Zip code:

Apt/ Floor:

Home/ Mobile Number:

Work Number:

{2} Parent/ Guardian’s First Name:

Parent/ Guardian’s Last Name:

Relationship to Child:

Street Address:

City, state, and zip code:

Apt/Floor:

Home/mobile Number:

Work Number:

Non- Refundable $25.00 Registration fee must be paid in full for this child after completing registration form to hold placement.

(All checks made payable to: AMA Family Daycare)

Does the child have any medical conditions? YES        NO

If YES, What medical conditions does the child have?

______________________________________________________

Is the Child on medication? YES           NO

If YES, What Kind of Medication?

______________________________________________________

Does the child have any Physical, Mental, and/ or emotional disabilities? YES NO

If YES, Indicate the disabilities and affect ness to A. M. A. program activities?

______________________________________________________

Is child Potty Trained? YES        NO

If NO, Would you like A. M. A. to work with you to help potty train you child once he/she shows interest in potty training? YES        NO

Please indicate your child’s Likes, Dislikes and/or Special Interests:

(Such as certain foods, songs, books, cartoon characters ect.)

_________________________________________________________

Parent/ Guardian :__________________________ 

Date:_______/_______/_______

Parent/ Guardian :__________________________

Date:______/________/_______

Thank you for registering with A. M. A. Family Daycare, we look forward to working with you and your child.

A. M. A. Family Daycare Use ONLY:

Was interview done? YES NO

If No, was interview scheduled: YES NO

If Yes, when? _______/_______/_______ at ____:_______ am pm

Child’s START date: ________/________/_______ Full- Time Part-Time

Non Refundable $25.00 fee was paid in form of: Cash Check Money Order

Received By:______________________________ Date:_______/________/________

NOTES: Provider stamp: