Enrollment Form

Bee Happy Day Program

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Enrollment Form

Download to Print Form

Welcome to enrollment! You may download the form by clicking the button above and filling out then emailing to info@beehappydayhab.org or fill out the online form below. Thank you.

For any questions, please CONTACT US directly.

Bee-Happy Enrollment Form & Application

* Indicates required field

Your Name (Person signing up on behalf of others or yourself if an attendee.) *

First

Last

Attendee Name (If someone other than yourself.) *

First

Last

Phone Number *

Email *

Preferred Method of Contact *

Email Call Cell Call Home Call Work

Life Skills Training

*To be filled out by parent/guardian, important information we should know.

Please list any frustrations or key triggers of the attendee (Busy Bee client). *

Please list any activities or things the Busy Bee client may enjoy the most. *

Please list any fears/anxieties we should be aware of in regards to the Busy Bee client. *

Please list any primary goals you are looking to achieve. *

Please include anything else that might be important. *

Authorization

Date *

Type your name in below for your approval and authorization. (Guardian) *

Date *

Type your name in below for your approval and authorization. (Other Guardian.) *

Transportation

If you require transportation, please let us know where you would like to be picked up.

Address *

Line 1

Line 2

City

State

Zip Code

Country

With Whom Do you Live *

Group Home Parents Guardian Other

Attendee Height *

Attendee Weight *

Attendee Gender *

What program are you using? *

HCS TXHML CLASS PRIVATE PAY OTHER None, does nto apply

Name of Service Provider *

Level of Need (Please circle one) *

What type of transport will you need? *

Guardian Group Van Star Transit Other

Get to Know You.

Check the activities you like to do. *

Board Games Arts & Crafts Electronic Games Listening to Music Sports Reading Other

If you selected OTHER or have other activities you are interested in, please list them below. *

Reading Skills (Please select your level of reading.) *

I can read independently. I can read some words. I need to be read to.

Writing Skills (Please select your level of writing.) *

I can write independently. I can write some words. I can't write.

What important details do you want us to know to help serve you better: *

Do you have any activity restriction? *

Medical Information

In the event of a medical emergency, what hospital do you prefer? *

Closest One Available I have a preferred Hospital

If you have a preferred hospital, please provide the name below. *

Please check if you have any of the following. *

Asthma Emotional Disturbances Cerebral Palsy Heart Condition Contact Lenses Hepatitis Contact Lenses Seizure Disorder Other

If you listed other or have any other medical conditions you would like to include or share, please include them below. *

Please include your list of medications below.

Name of Medication *

Dosage *

Time Taken *

Name of Medication *

Dosage *

Time Taken *

Name of Medication *

Dosage *

Time Taken *

Please include any other medications, dosage and time taken information below. *

If you have a list of medications document, you may upload it here, otherwise you can skip to the next section. *

Max file size: 20MB

Please list any allergies you have to any foods. *

I agree to receiving marketing and promotional materials *

Submit

*Please also download the following form that requires final signatures including emergency, authorizations, and payment information. Please be sure to download, sign, and email to info@beehappydayhab.org

bee-happy_signature_pages2.pdf
File Size:	280 kb
File Type:	pdf

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Bee-Happy Day Program
106 N. Washington St
Kaufman, TX 75142
Phone: (972) 645-4449
Serving Kaufman County & Surrounding Areas

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Home
Services
Enroll Now
Reimagine
Get Involved
About
In Memory