Student Background Form
This form is split into 6 sections and it will take about 15 minutes to complete it. The data is only saved upon its submission at the end.
The information collected here is for the Kids Connect team to get to know the learner's background as well as his immediate community It is for internal use only and is kept confidential.
Thank you for taking your time to helping us get to know your child.
* Required
Date of Application
*
MM
/
DD
/
YYYY
What program are you interested in?
*
Tailor Made
School Shadowing
Social Club
Let's Party
Games On!
Finger Power
Yes! Attention
Story.... la la la ~
Artsy Art
Consultation
BCBA Supervision
Special Request
Will discuss in person
Required
Child's First and Middle Name
*
Your answer
Surname:
*
Your answer
Name in Chinese:
(If applicable)
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Nationality
*
Your answer
School Currently Attending
Your answer
Grade
Your answer
Class Time in School
Morning
Afternoon
Whole Day
Clear selection
Sex
Male
Female
Clear selection
Address: Building Name/Tower/Flat
*
Your answer
Address: Street Number and Street Name
*
Your answer
Address: District
*
Central, Causeway Bay, Wan Chai etc
Your answer
Home Phone Number
Your answer
Where did you hear about us?
Professional Referral
Friend
Education Setting
Found by Searching Online
Social Media
Other:
Clear selection
Can you provide a name or an organization for our reference only.
Your answer
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