Student Enrolment Form

Please fill out the student enrolment form and we'll get back to you as soon as possible.

Choose Session

Saturday 9:00am - 11:30am

Saturday 3:00pm - 5:30pm

Sunday 9:00am - 11:30am

Sunday 3:00pm - 5:30pm

Primary contact

First Name *

Last Name *

Phone *

Email *

Secondary contact

Secondary Parent First Name

Secondary Parent Last Name

Secondary Number

Secondary Email

Student Information

Students Full Name *

Date of birth

Address *

Street Address

City

State

Country

Postal Code

Is your child subject to epilepsy, seizures, diabetes, asthma or any or conditions that might effect his or her condition during classes at Holara Education?

Yes

No

If yes, please provide details

Does your child have any allergies? *

Yes

No

Please list any allergies below

Does your child take any medications? *

Yes

No

If yes, please name the medications, dosage and frequency

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