KQES Student Registration Form

Student’s Name *

Country of Birth*

Name of School*

Current School Year*

Date of Birth*

Male

Female

Language(s) spoken at home*

Cultural Background*

Student Information.

Reasons for joining the KQES Network program

What are your favourite subjects at school?

What subjects does you need help with?:

Do you have any medical/health problems?

yes

If yes, please give further information

Do you regularly take any medicine?

yes

If yes, please detail

Do you have any special needs that the program needs to know about?

yes

If yes, please give further information

How did you find out about the KQES Network program?

Parent / Guardian Name*

Home Address*

Postcode*

Telephone*

Email*

Mobile*

To be part of this program, it is important that you:

Signature*

I give permission for my son/ daughter to participate in the KQES Network.

Yes No – I allow my child to walk to home from KQES activities unsupervised

Yes No – I do not allow my child to be filmed, taped or photographed

In case of emergency, I can be reached at this phone number

I plan on attending the induction day for the KQES Network

Signature*

Date*

Name ( PLEASE PRINT )