Registration

Name

Address

Phone

Email Address

Registration Date: dd/mm/yyyy

Where did you hear about us?

How many children would you like to register? How many children would you like to register?1234

Student 1 Details

Gender Gender Male Female

Date Of Birth: dd/mm/yyyy

What school or preschool does your child attend?

Has your child had lessons previously Has your child had lessons previously No Yes

Where

Why did you leave?

Student 2 Details

Gender Gender Male Female

Date Of Birth: dd/mm/yyyy

What school or preschool does your child attend?

Has your child had lessons previously Has your child had lessons previously No Yes

Where

Why did you leave?

Student 3 Details

Gender Gender Male Female

Date Of Birth: dd/mm/yyyy

What school or preschool does your child attend?

Has your child had lessons previously Has your child had lessons previously No Yes

Where

Why did you leave?

Student 4 Details

Gender Gender Male Female

Date Of Birth: dd/mm/yyyy

What school or preschool does your child attend?

Has your child had lessons previously Has your child had lessons previously No Yes

Where

Why did you leave?

Medical / Emergency Contact Medical / Emergency Contact Are there any learning difficulties or medical conditions we should know about? No Yes

Please explain

Doctor's Name

Doctor's Phone Number

Emergency Contact Person

Relationship To Student

Emergency Contact Number

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