Registration Form

A M A Family Daycare

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Today’s Date: ____/____/____                              

Child’s First Name:

 

Child’s Middle Name:

 

Child’s Last Name:

 

Date of Birth: ____/____/_____

 

Desired Start Date: 

______/________/_____

 

Names of Siblings enrolled with A.M.A:

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{1} Parent/ Guardian’s Full Name:

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Relationship to Child:

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Complete Address:

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Best number to reach you at:

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{2} Parent/ Guardian’s Full Name:

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Relationship to Child:

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Complete Address:

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Best number to reach you at:

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Please send Non- Refundable $25.00 Registration fee (Check,MoneyOrder,Zelle-3472487368) with this registration form to hold placement on waiting list. Waiting list placement does not guarantee spot.

 

(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?

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______________________________________________________

 

Is the Child on medication?    YES           NO

 

If YES, What Kind of Medication?

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______________________________________________________

 

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?

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______________________________________________________

 

Is child Potty Trained?   YES        NO

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

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

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_________________________________________________________

 

 

 

Parent/ Guardian :__________________________ 

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Date:___/____/___

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Parent/ Guardian :__________________________

 

Date:___/____/___

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Thank you for registering with AMA 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:_______/________/________

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