Registrations – Kanooka School House

Child's Particulars

Name as in Birth Certificate / Passport*

Chinese Character (if any)

Birth Cert No/ UIN / FIN*

Date of Birth*

Age*

Please enter a value between 1 and 18.

Gender*

Male
Female

Nationality*

S'pore Citizen
Permanent Resident

Race*

Chinese
Indian
Malay

Religion*

Language / Dialects Spoken At Home*

Residential Address*

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

Home Tel No*

Name of Father*

First Name Last Name

Father's Mobile No*

Name of Mother*

First Name Last Name

Mother's Mobile No*

Child's Medical History

Fits*

Yes
No
Unknown

Asthma*

Yes
No
Unknown

Physical Impairment*

Yes
No
Unknown

Allergies

(Food)

(Drug)

Special Diet

To the best of my knowledge my child is healthy*

Yes
No

Immunisation Record

B.C.G.

Diphtheria, Pertussis and Tetanus (DPT/DT vaccine)

1st dose

2nd dose

3rd dose

Poliomyelitis (Polio vaccine)

1st dose

2nd dose

3rd dose

Measles, Mumps, Rubella Vaccine

Diphtheria, Pertussis and Tetanus (DPT/DT vaccine)

1st dose

2nd dose

3rd dose

Poliomyelitis (Polio vaccine)

Hepatitis B

1st dose

2nd dose

3rd dose

In Case of Emergency

Name of Doctor

First Name Last Name

Contact No

Name of Clinic

Address

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