Registration Form
SeDidik Sdn Bhd
Date
Centre
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Registration Information
A. Children Information
First Name
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Date of birth
Father Name
Birth Certificate
Place Of Birth
Gender
Male
Female
Relegion
Race
Address
Correspondence
Poscode
State
B. Medical & Health Information
Child ( Premature )
Birth ( Method )
No
Yes
Normal
Vaccum
Forcep
Caesaerean
Doctor's Name
Phone No.
Address
Health Record
Fits
Yes
No
asthma
No
Yes
Diabetis
Yes
No
Allergy
Yes
No
Others
Yes
No
C. Parent / Guardian Details
Father
Mother
Name
Name
IC No.
IC No.
Date of birth
Date of birth
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Nationality
Nationality
Relegion
Relegion
Race
Race
Profesion
Profesion
Office Address
Office Address
Office Phone No.
Office Phone No.
Phone No.
Phone No.
Highest Education
Highest Education
Email Adress
Email Adress
D. Emergency Cases
In case of emergency, the closest next of kin that can be contact?
Relationship
Name
IC No.
Phone No.
E. DISCLAIMER
hereby
IC No.
I
Checked that all information in this form are absolutely true, and i understand the rules & regulation that has been stated by this centre
*Note
Please bring along during registration :
1. Clinic Card
2. Photocopy of father & mother
3. Pasport size picture (children)
4. Photocopy of birth certificate
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