B.E.A.M.

Microschool Academy Registration Form

Parents First Name *

Parents Last Name *

Parents Email *

Phone *

Relationship to the student *

Address

Street Address

City

State

Country

Postal code

Emergency Contact

Emergency Contct Full Name *

Emergency Contact Phone # *

Emergency Contact Relationship to Sudent *

Student Information

Child's First Name

Child's Last Name

Child's Date of Birth*

Child's Current Grade Levels

Child's Current School

Child's Desired Enrollment Date*

Arrival, Dismissal & Extended Care Options

Standard School Day Schedule (please choose one):

Option 1: 8:00 AM – 3:00 PM

Option 2: 10:00 AM – 5:00 PM

Please indicate if you require extended care (additional $100.00)

(8:00 AM – 3:00 PM): Extended care provides coverage before school from 7:00 AM to 8:00 AM.

Type an Option(10:00 AM – 5:00 PM): Extended care provides coverage after school from 5:00 PM to 7:00 PM.

No, I do not require extended care.

Student Background & Special Needs

Student Interests & Strengths:

Special Accommodations/Challenges:

Health & Allergy Information:

How did you hear about us?

Communication Preferences

Preferred Method of Contact (mark all that apply)

Text

Phone Call

Mail

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Payment & Registration Confirmation

Please note your registration is only complete once you've successfully completed your payment below.

Payment Processing Section

Signature

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