Therapy Registration Form

Student's Details

Choose Activity*

Upload Colour Photo/IC

Name (Chinese)

Name as per IC (English)*

Birth Cert/Identity Card No. (Example: 990504145558)*

Date of Birth

Age (Please specify years and months)

Gender*

Position among Siblings

School/Kindergarten

Is there any Physical or Psychological Health Conditions?*

If there’s any allergy or disease, please prepare own medicine.

* If there's any allergy or disease, please prepare own medicine.

Strength

Weakness

Preferred communicating language (interaction between therapists and child) Chinese English Bahasa Melayu Others

Parent/Guardian's Details

Name (Chinese)

Name as per IC (English)*

Identity Card No. (Example: 810504145558)

Occupation

Contact No. (Example: 0388889999)

Mobile No. (Example: 0127777888)*

Email Address*

Fax No.

Membership E-Card ID

Preferred communicating language (such as home activity, letter or notice) Chinese English Bahasa Melayu Others

Home Address

Address Line 1*

Address Line 2

Postcode*

City*

State*

Country*

Emergency Contact

Name (Chinese)

Name as per IC (English)

Contact No. (Example: 0388889999)

Relationship to Child

Other Details

Introduced by

If knowing us through other platforms, please specify

Are you willing to provide car pool service?*

备注：完成报名之前，请参阅相关儿童疗育家长 / 监护人同意书。
Note: Please go through our Parents/Guardians Informed Consent before registering.

付款方法 Payment Method

1．银行转账/现金付款/信用卡付款。
1．Bank Transfer, Cash or Credit Card payment.

2．支票或邮政汇票抬头请注明: Azon Connect People Development Sdn Bhd
2．For payment by cheque, please state: Azon Connect People Development Sdn Bhd

3．现金汇款或网上付账请汇入批 Public Bank A/C No.: 3202636531, 然后将收据传真或电子邮件至本公司。
3．For bank transaction or online payment, please pay to Public Bank A/C No.: 3202636531 then email or WhatsApp the bank slip to us.

E-03-22 IOI Boulevard, Jalan Kenari 5, Bandar Puchong Jaya, 47100 Puchong, Selangor, Malaysia.

Mobile No: +6019-297 1431

Email: info@azon.my

Website: www.azon.my

Parent/Guardian Declaration

I hereby allow my son/daughter as registered above to participate in this activity. I have read the terms and conditions of this activity. I believe that Azon will provide good supervision throughout the activity. I understand that if any unforseen accident happens, Azon shall not bear any legal responsibility.

I agree*

My Identity Card No. (Example: 801205069657)*

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