Einstein Kidz Abacus

Centre Name * :

Program * :

Child Name * :

Age * :

Parents Name * :

Home Address :

Suburb * :

Contact No * :

Email * :

Emergency Contact Name :

Emergency contact No :

Medical Condition :

Does your child have any disability (i.e. Physical/intellectual/behavioral), illness (i.e. asthma) and / or allergies we should know about?

YES NO

Declaration :

I give my consent for my child / children in my care to be photographed for the purposes of activities she/he/they participate/ I understand the photographs or videos will only be used strictly for the purposes of the program reporting, promotion and updates.

How did you came to know about Einstein kidz ? *

I agree to terms and conditions to register my child / children.