-


-

 Fill in the information in each section as required.

Do not leave fields with * blank.

 
 

Registration Form

 
Full Name :*
Address :
Gender :
Birth Certificate No.*
Nationality :
Date of Birth :
School Attending :
Religion :
Session & Class :
Father's Name :*
NRIC No. :
Occupation :
Name of Employer :
Address of Employer :
Pager No. :
Handphone :
Office No. :
E - Mail Address :
Mother's Name : *
NRIC No. :
Occupation :
Name of Employer :
Address of Employer :
Pager No. :
Handphone :
Office No. :
E - Mail Address :
Parent / Guardian's Name with Legal Custody :
Relationship :
NRIC No. :
Occupation :
Name of Employer :
Address of Employer :
Pager No. :
Handphone :
Office No. :
E - Mail Address :
In Case of EMERGENCY , please state particulars of person to contact ( other than parents ) ;
Primary  
Contact Person:
NRIC No.:
Relationship:
Contact No.:
Address:
Secondary  
Contact Person :   
NRIC No. :
Relationship:
Contact No.:
Address :
Family Doctor Information  
Name of Family Physician :
Name of Clinic :
Telephone No.:
Address :
 
Child's Name :
Date of Birth :
Recorded by :
Illnesses  
Does your child have any health problems as shown in the following ? Has your child ever suffered from any of the following before ?
Constipation
Convulsions
Diarrhea
Fainting Spells
Frequent Cold
 Frequent Ear Infection
Frequent Sore Throat
Lice
Ringworm
Skin Rash
Soiling
Stomach Upsets
Urinary Problems
Worms
Asthma
Bronchitis
Chicken Pox
Diabetes
German Measles
Heart Disease
Hepatitis
Impetigo
Measles
Mumps
Polio
Scarlet Fever
Tuberculosis
Whooping Cough
Others ILLNESSES ?
Has your child ever been HOSPITALISED ?
If Yes, please elaborate
Has your child ever had serious INJURIES before ?
If Yes, please elaborate
 
Child's Physician
Name of Clinic
Telephone Number
Fax Number
Address
Postal Code
Medicine Allergies
Food Allergies
Others Allergies
Blood Type
Special Health Conditions

 

  
[index] [top] [About TLC] [Programs] [Registration] [Others] [email]