CMI Remedial Lessons - Student Admission Form

Remedial Lessons Admission Form

Caribbean Mind Institute is a specialty institution which caters to the educational needs of children who are in need of specialized or individual attention.
School Information

Tel: 546-6925/257-1124 | Email: info@caribbeanmindinstitute.com | Location: 6th Ave, Belleville, St. Michael
Personal Information
Student's Name:*

First NameMiddle NameLast Name
Gender:*

MaleFemale
Date of Birth:*

MonthDayYear
Address:*

Street Address

Street Address Line 2

ParishCity

Postal / Zip CodeCountry
Health Concerns
Please list any allergies or serious illnesses to date:*
Parent/Guardian Information
Mother's Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number:*
Format: (000) 000-0000.
Cell Number:*
Format: (000) 000-0000.
Work Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Email:*
example@example.com
Father's Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number:*
Format: (000) 000-0000.
Cell Number:*
Format: (000) 000-0000.
Work Number:*
Please enter a valid phone number.Format: (000) 000-0000.
E-mail:*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number*
Format: (000) 000-0000.
Education
Present School:*
Class Level:*
Areas of Concern:*
Observations: (For Teaching Staff to complete)
Should be Empty:

Remedial Lessons Admission Form

School Information