Preparing a Demo

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Children sitting by a table in Holistic Center

Registration Form

Child's Information

Name *

Mobile Phone

Email

Date of Birth *

Gender

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Does your child attends school? *

Which School your Child Attends *

How your child attends

Physical school

Online school

Or Both

Does your child have any know alergies *

Yes

No

Not Sure

If yes what is it?

Does your child have any known medical conditions *

Yes

No

Not Sure

If yes what is it?

Does your Child have any known physical disability *

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If yes what is it?

Parents/Guardian Information

What Relation Your'e To Child? *

Full Name *

Email: *

Mobile Phone: *

What Is Your Profession *

Current Employer *

Name & number of Contact In Case Of Emergency *

Relationship To Child *

Address: *

Choose Your Package

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Optional Services We Offered @ Additional Price By Request

Do you Request? Choose All That Apply

Breakfast

Lunch

Dinner

Traditional Snack

Fruit Snack

Pick Up From School

Yes

No

Not Sure

Today's Date

Signature :By Typing Your Name Here You Acknowledge That the information above is true and you are authorise Parent/guardian to enrolled this child,also that you are committed to pay all fees when they become due *

Official Use Only

Interviewer Name

Notes

Child Accepted

Yes

No

Date when accepted

Remarks

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