Contact - Empowered Minds Learning Center

Student Details

Student's Full Name

Date of Birth

Gender

Nationality

Upload Birth Certificate/Identification

Grade/Level Applying For

Preferred Start Date

Does the student have any siblings enrolled in this school?

Yes No

If yes, list their names

Parent/Guardian Information

Primary Parent/Guardian

Full Name of Parent/Guardian

Relationship to Student

Phone Number

Email Address

Occupation

Upload a Copy of Your Identification Card

Secondary Parent/Guardian

Full Name of Parent/Guardian

Relationship to Student

Phone Number

Email Address

Occupation

Upload a Copy of Your Identification Card

Educational Background

Previous School Name

Address of Previous School

Last Grade/Level Completed

Reason for Leaving Previous School

Upload Copies of Previous School Records

Health and Special Needs

Does the student have any learning difficulties or special needs?

Yes

If yes, provide details and upload supporting documentation:

Does the student have any medical conditions or allergies?

Yes

If yes, provide details:

Is your child on any regular medication?

Yes

If yes, specify the medication and dosage:

Has your child received all recommended immunizations?

Yes

If no, please specify: Attach a copy of your child’s immunization record:

Permissions

I authorize the center to administer basic first aid to my child in case of minor injuries

Yes

In case of an emergency, I authorize the center to seek medical attention for my child if I cannot be reached

Yes

Program Information

Which curriculum would you prefer for your child?

Are there specific areas of academic focus or goals for the student?

Emergency Contact Information

Emergency Contact Name

Relationship to Student

Phone Number

Declaration

I, the undersigned, hereby declare that the information provided in this application is true and complete to the best of my knowledge. I understand that providing false or incomplete information may result in the rejection of this application or termination of enrollment.

Parent/Guardian Name

EMPOWERED MINDS

Download Supporting Documents

Enrollment Form

Student Details

Parent/Guardian Information

Primary Parent/Guardian

Secondary Parent/Guardian

Educational Background

Health and Special Needs

Permissions

Program Information

Emergency Contact Information

Declaration