Customer Registration Form Please fill in required fields marked with an *Child's detailChild's First Name *Last Name *Date of Birth *Nationality *Gender *MaleFemaleHas siblings in Atelier programmes *NoYesName Parent's detailParent's First Name *Last Name *Mobile *Email *Home phone number (in event of emergency) Office phone number (in event of emergency) Home Address *Other parent’s detailParent’s First name *Last Name *Mobile *Email *Alternative Caregiver's detailCaregiver’s First name Last Name Mobile Relationship to the child Emergency Contact Information (If different from Parents’ information stated above)First name Last Name Mobile Email *Medical InformationIs your child/ren currently up to date with their age appropriate vaccinations? *YesNoDoes your child/ren have any medical disabilities or special education needs? *YesNoIf yes, please provide further details Does your child/ren have any medical problems or allergies, including food allergies? *YesNoIf yes, please provide further details Is there anything else you would like us to know about your child? *YesNoIf yes, please provide further details How did you hear about Blue House Infant & Toddler Atelier? (Please tick) *GoogleInstagramFacebookWord of mouthFriendWebsitePublication (Please specify below)Other (Please specify below)Publication e.g. Sassy Mama, Honey Kids, Little Steps, Expat Living (Please specify) Other (Please specify) I confirm that I have read, understood and agree to abide by the Terms & Conditions. *OK Please read the Terms & Conditions in here. VerificationThis box is for spam protection - please leave it blank: