Student Registration Form

Student Registration Form

Fill out the form carefully for registration
If you have any questions please call us on +1 876 844 3928
Student Name*

First NameMiddle NameLast Name
What s/he likes to be called:
Birth Date*

MonthDayYear
Gender*
Student Age*
Which program are you registering for:
School Attended
First Language
Parent/Guardian Details*

First NameMiddle NameLast Name
Address (Street Address, City, State / Province & Postal / Zip Code)*
Work Address (Street Address, City, State / Province & Postal / Zip Code)*
Does the student have a NSRS

YESNO
If YES, please provide details.
Does this child normally live at this address?

YESNO
Parent's E-mail*
example@example.com
Mobile Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Does this person have parental responsibility?

YESNO
Does anyone else have parental responsibility for this child?

YESNO
If YES, please provide details.
Emergency Contact Details*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to the child
Please state the names of any other authorised people who will be able to collect your child
Child Doctor

First NameLast Name
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor's Phone Number

Area CodePhone Number
About Your Child
Please detail any additional/special needs your child has: (Please provide full details)
Please detail any dietary requirements/Food allergies for your child (Please provide full details)
Is there anything your child doesn't like (Food, games etc) or is scared of?
What are your child's favourite activities?
Additional Comments
Signature*

Clear
Take Photo*
How did you hear about us:

Social MediaWord of mouth
Should be Empty:

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About Your Child