AliCaT Registration Form
Please fill out the form below to register your child or children
* Required
Carer First Name
*
Your answer
Carer Last Name
*
Your answer
Child 1 First Name
*
Your answer
Child 1 Last Name
*
Your answer
Child 1 Date of Birth
*
MM
/
DD
/
YYYY
Child 2 First Name
Your answer
Child 2 Last Name
Your answer
Child 2 Date of Birth
MM
/
DD
/
YYYY
Child 3 First Name
Your answer
Child 3 Last Name
Your answer
Child 3 Date of Birth
MM
/
DD
/
YYYY
Contact Email Main
*
Your answer
Contact Email Other
Your answer
Contact Phone Main
Your answer
Contact Phone Mobile
Your answer
Contact Phone Other
Your answer
Emergency Contact First Name
*
Your answer
Emergency Contact Last Name
*
Your answer
Emergency Contact Phone
*
Please use a number that is always monitoured
Your answer
Address 1
*
e.g. house name or number
Your answer
Address 2
*
e.g. road name
Your answer
Address 3
*
e.g. city or town
Your answer
Address 4
*
e.g. postcode
Your answer
Medical and Support Needs
please add information for each child, e.g. Child 1..., Child 2..., Child 3...
Your answer
School Attending Child 1
*
Your answer
School Attending Child 2
Your answer
School Attending Child 3
Your answer
How did you find out about AliCaT?
Friend
School
Web
Word of Mouth
Add any additional information here
Your answer
Select if you would like a Free Trial Class
Free Trial Class
I Agree to the AliCaT Terms & Conditions
*
terms link here:
https://bit.ly/2JN19I5
I agree
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