Registration - B-Smart Edu Centre

Student Enrollment

Name(Required)

First Last

Relationship(Required)

Residential Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address

Tel (Home)

Tel (Work)

Mobile Number(Required)

Email(Required)

How did you learn about us?

Through a Friend

School Newsletter

Flyer

Website

Recommendation by School

Other

Student Particulars

Name(Required)

First Last

Date of Birth(Required)

School Name(Required)

Enrollment for which of the following

Reading (AFR)

Reading (ENG)

Maths

Online Reading

TOVA

Neuro Focus

Evaluation

You may select more than one option

Parent / Guardian Consent

Name

First Last

Date

Parent / Guardian ID Number

Person responsible for this account

Personal Information Consent

By ticking this box you agree that we may collect your personal information

POPI Act Agreement

Indemnity Agreement

By ticking this box you accept our Indemnity Agreement

Indemnity Agreement

Terms and Conditions

By ticking this box you agree to the terms and conditions

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Name

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Register your child

Student Enrollment

Student Particulars

Parents Questionnaire

Parent / Guardian Consent

Scriber | Reader | Prompter Contact Form