KidsQuest - Enrollment Form

Student Name *

Student Surname *

Gender *

Date of Birth *

Current Age

Fears (e.g., Spiders, Heights)

Details of Habits (e.g., Biting Nails)

Learning Problems

Details of Any Speech Difficulties

Allergies

Medical Aid *

Yes No

Medical Aid Name

Medical Aid Number

Family Doctor

Any Health Conditions We Should Be Aware Of

Parent/Guardian Surname *

Parent/Guardian Full Names *

Cell Number *

WhatsApp Number *

Email Address *

Residential Address *

Toilet Training - Do They Need Help? *

Yes No

Please Supply Details If They Need Help

Who May Collect The Student From KidsQuest *

Emergency Contact (Other Than Parent) *

Relation to Student *

Emergency Contact Cell Number *

Extra Attachment