Child’s Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Date of Birth *

MM

DD

YYYY

Parent's Cellphone *

(###)

###

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Work Number *

(###)

###

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Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact's Full Name (*Details must be different from Parent/Guardian) *

First Name

Last Name

Emergency Contact's Number (*Details must be different from Parent/Guardian): *

(###)

###

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I understand that Kgololo Academy reserves the right to verify the information included in this form, which may include contacting my employer to verify my employment and salary. *

Yes, I understand.