Child's name: ..…………………………………………………. Date of Birth: …………………… Sex: …………

Nationality: …………………………………………………….. Speak English: Yes [ h] tttttttttttt No [ h]

Name of Father: ………………………………………………. Speak English: Yes [ h] tttttttttttt No [ h]

Name of Mother: ………………………………………………. Speak English: Yes [ h] tttttttttttt No [ h]

Home Address: ……………………………………………………………………… Tel: ………………………….

Father's Business Address: …………………………………………………………… Father's Age* …………..

………………………………………………………………………………………….. Tel: …………………………

E-mail: ……………………………………………………

Mother's Business Address: . ………………………………………………………….. Mother's Age* …………..

………………………………………………………………………………………….. Tel: ………………………….

E-mail: ……………………………………………………

Emergency Contact Number

Name: ………………………………………………………….. . Relationship (if any): …………………………….

Tel: ………………………………………………

Important: In the event of an accident requiring medical attention, he/she will be taken to Bangkok Samitivejl Hospital. You will be contacted immediately. IPC International Kindergarten and IPC's 1 to 3 will not be responsible for any medical costs incurred.

Please give details of any allergies or medical problems your child has:

……………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………….

Number of children in your family: …………………………..

Comments: ………………………………………………………………………………………………………………….

…………..……………………………………………………………………………………………………………………

Please list the adults authorised to collect your child from school: Please note that we require all adults to produce an I.P.C. ID card (available from Office) when picking up a child from school.

……………………………………………………………………

……………………………………………………………………

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Mother's Signature

…..………………………………………………….
Father's Signature

Date ……………………………..

* We require this information for
our official Thai records

Please print this form, fill it in and bring it along with you when you visit IPC or fax it to us.