Saturday and After School Classes Student Registration Form

Extra Classes Registration Form

Fill out the form carefully for registration:
If you have any questions please call us on +1 876 844 3928
Which Classes are you registering for:*

Saturday ClassesAfter School ClassesSummer School
Tick which area you would like your child to take part in

Reading ClinicPEP
Student Name*

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

MonthDayYear
Gender*
Student Age*
1st Parent / Guardian
Details*

First NameMiddle NameLast Name
Mobile Number*

Area CodePhone Number
Parent's E-mail*
example@example.com
1st Parent/Guardian Address (Street Address, City, State / Province & Postal / Zip Code)*
Place of Work
Work Number

Area CodePhone Number
2nd Parent / Guardian
Details*

First NameMiddle NameLast Name
Mobile Number*

Area CodePhone Number
Parent's E-mail*
example@example.com
2nd Parent/Guardian Address (Street Address, City, State / Province & Postal / Zip Code)
Place of Work
Work Number

Area CodePhone Number
Medical

Medical History*

	YES	NO	DATES	REMARKS
Asthma / Bronchitis
Rheumatic Fever / Rh. Heart Disease
Congenital / other Heart Disease
Sickle Cell Trait / Disease
Seizures (Epilepsy / Fits Fainting spells / Giddiness Anaemia weak blood)
Excess Tiredness
Disorders of the Ears, Nose, Throat
Diabetes Mellitus (Sugar)
Chronic Disease (e.g. Cancer / Thyroid
Arthritis
Recurrent Headaches / Migraine
Visual or Hearing Disorders
Physical Disability
Infectious Disease (e.g. Measles, Tuberculosis (TB), Mumps, Typhoid fever, Allergies to: penicillin / Antibiotics
Allergies to any other substance
Any other condition
Has your child ever been admitted to hospital or had surgery (if YES please explain for what reason)

Emotional History (Has your child ever been diagnosed with the following?)*

Has your child experienced any of the following?*

	YES	NO	DATES	REMARKS
Recent Stress e.g. death or relocation of a close family member, relative or friend?
Difficulty making friends, adjusting to new situations
Difficulty concentrating in class
History of fighting / hurting others

Family History (Has any family member been diagnosed with the following*

Additional Information
Name and number (s) of person (s) other than parents allowed to pick up your child
Please list any other information you would like to include about your child. (Medical information etc.)
Please upload a headshot photo of your child here (optional):
Signature*

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How did you hear about us:

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Extra Classes Registration Form