Registration Form

Registration Fee: N$300.00

Child Information

Child Full Name *

Preferred Name

Date of Birth - Year *

Month *

Day *

Address *

Parent Information

Parent 1 Name *

Parent 2 Name

Parent 1 Home Phone

Parent 1 Cell Phone *

Parent 1 Email

Parent 2 Home Phone

Parent 2 Cell Phone

Parent 2 Email

Parent 1 Workplace

Parent 1 Work Phone

Parent 2 Workplace

Parent 2 Work Phone

Enrollment Date

Year *

Month *

Day *

Emergency Contacts

Emergency Contact 1 Name *

Emergency Contact 1 Home Phone *

Emergency Contact 1 Relationship

Emergency Contact 1 Work/Cell Phone

Emergency Contact 2 Name

Emergency Contact 2 Home Phone

Emergency Contact 2 Relationship

Emergency Contact 2 Work/Cell Phone

Medical Information

Doctor Name

Doctor Address

Doctor Phone

Doctor City

Doctor Postal Code

Health Card Number

Health Card Expiry

Allergies

Yes

Allergies Details

Foods Disliked

Outdoor Play Notes

Toilet Trained

I confirm that the information provided is accurate and complete.