Registration Form

Siyafunda Community Technology Centre

72 Celtis Street, Palm Ridge, Katlehong, 1458

info@siyafundactc.org.za

www.siyafundactc.org.za

011 904 2720

067 011 8748
Registration Form
- Full Name*
  
  First NameMiddle NameLast Name
- Birth Date*
  
  MonthDayYear
- Identity / Passport No*
  e.g. 00010203456780
- Grade Obtained*
  Choose Grade - e.g. Grade 10
- Employment Status*
- Gender*
- Disability*
- Enter Course/Workshop Name*
  e.g. Office Administration
- Email
  example@example.com
- Phone Number*
  
  Area CodePhone Number
- Network Provider*
- Physical Address*
  
  Street Address
  
  Street Address Line 2
  
  CityProvince
  
  Postal Code e.g. 1432Country
- Emergency Contact*
  
  First NameLast Name
- Relationship*
  ex. Father, Mother, etc.
- Address Of Person To Contact In Case Of Emergency*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number Of Person To Contact In Case Of Emergency*
  Please enter a valid phone number.
- Email Of Person To Contact In Case Of Emergency*
  example@example.com
- Institute Last Attended*
- Other Extra Curricular Activities*
  Type N/A if you don't have any
- Resources Available*
  
  Internet/DataOwn CarLaptopPublic TransportPrinterPrivate Transport
- Skills/Talents*
  
  ActingArts/CraftsCalculatingDancingDebatingDrawingEatingFashionPhotographyPlaying drumsPlaying guitarPlaying pianoProgrammingSingingWritingOthers (specify below)
- Other Interests
- Total household income per month*
- Did receive any scholarships, Funding or bursary?*
  
  YesNo
- Who/what is the name of your sponsor?
- What is your plan after the course?*
- Suggestions / Comments
- How did you Hear About Us?*
- Please verify that you are human*
- Should be Empty: