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