Customer Registration Form

Please fill in required fields marked with an *

Child's detail

Child's First Name *

Last Name *

Date of Birth *

Nationality *

Gender *

MaleFemale

Has siblings in Atelier programmes *

NoYes

Name

Parent's detail

Parent'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 detail

Parent’s First name *

Last Name *

Mobile *

Email *

Alternative Caregiver's detail

Caregiver’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 Information

Is your child/ren currently up to date with their age appropriate vaccinations? *

YesNo

Does your child/ren have any medical disabilities or special education needs? *

YesNo

If yes, please provide further details

Does your child/ren have any medical problems or allergies, including food allergies? *

YesNo

If yes, please provide further details

Is there anything else you would like us to know about your child? *

YesNo

If 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. *
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• Please read the Terms & Conditions in here.

 

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