Wollert Community Pathshala Inc Registration Form

Wollert Community Pathshala Inc Registration Form

Web: wcpathshala.org E-mail: wcpathshala@gmail.com Contact:0403208958, 0478795520
Child's Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Email
example@example.com
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Current School Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Relationship
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Please give details
YesNo
Please pay $10 registration fee to the following Bank Account.

Account Name: WOLLERT COMMUNITY PATHSHALA INCORPORATED

BSB: 06 3777

Account Number: 1056 3553

Reference: Student Full Name

NB: Your personal information will be used in accordance with the Privacy Act.
Please upload a profile picture of the child

Cancelof
I am the parent/guardian of the child indicated above.If emergency medical care is needed and I am unavailable, I authorize the supervising teacher to seek medical treatment for my child.I am giving my permission to take my child's pictures for classroom projects and post them on our Community Facebook page.
Date

DayMonthYear
Date
Signature
Should be Empty: