Child Registration Application

Part A - Child Information

Child's Surname

Middle Name

Other Names

Home Address

Date of Birth

Sex

State of Origin

Religion

Parent's/Guardian's Name

Guardian Relation

Father's Occupation

Father's Phone No

Mother's Occupation

Mother's Phone No

Are Parents Together?

---------

Yes

Emergency Contact Name

Emergency Contact Phone No

Who Picks Child at Closing?

---------

Mummy

Daddy

Other

Part B - Medical Information (To be filled by Parents or Guardian)

1. Has your child/ward any physical defect?

---------

Yes

2. Does he/she suffer from epileptic fits?

---------

Yes

3. Does he/she have any skin diseases such as Ringworm?

---------

Yes

4. Does he/she suffer from stomach disorders?

---------

Yes

5. Is he/she prone to cold?

---------

Yes

6. Is he/she a sicklier (i.e., Sickle cell anemia)?

---------

Yes

7. Is he/she allergic to anything?

---------

Yes

8. If yes to (7), please state

10. Does he/she have any respiratory disease such as Asthma or Bronchitis?

---------

Yes

Required Documents

Birth Certificate

Upload child's birth certificate (PDF, JPG, PNG)

Passport Photographs

Upload passport photograph (JPG, PNG)

Parent/Guardian Signature

Upload parent/guardian signature (JPG, PNG, PDF)

Declaration

Parent/Guardian Name (Final)

Date

Declaration: I hereby declare that the information provided is true and complete to the best of my knowledge. I agree to abide by the rules and regulations of Lipari Learning Academy Limited.