Therapy Registration Form

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019-231 7154 | 011 1431 0558 | 019 297 1431
info@azon.my

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Therapy Registration Form

Student's Details

Choose Therapy*

Upload Colour Photo/IC

Name (Chinese)

Name as per IC (English)*

Birth Cert/Identity Card No. (Example: 990504145558)*

Date of Birth

Age (Please specify years and months)

Gender*

Position among Siblings

School/Kindergarten

Is there any Physical or Psychological Health Conditions?*

If there's any allergy or disease, please prepare own medicine.

* If there's any allergy or disease, please prepare own medicine.

Strength

Weakness

* Please attach student's recent colour photo and photocopy of IC (or Birth Certificate)

Parent/Guardian's Details

Name (Chinese)

Name as per IC (English)*

Identity Card No. (Example: 810504145558)

Occupation

Contact No. (Example: 0388889999)

Mobile No. (Example: 0127777888)*

Email Address*

Home Address

Address Line 1*

Address Line 2

Postcode*

City*

State*

Country*

Emergency Contact

Name (Chinese)

Name as per IC (English)

Contact No. (Example: 0388889999)

Relationship to Child

Other Details

Introduced by

How did you get this information?* Radio Magazine Internet Friend Phone Fax SMS Email Others

If knowing us through other platforms, please specify

Preferred communicating language (such as home activity, letter or notice) Chinese English Bahasa Melayu Others

Parent/Guardian Declaration

I hereby allow my son/daughter as registered above to participate in this activity. I have read the terms and conditions of this activity. I believe that Azon will provide good supervision throughout the activity. I understand that if any unforseen accident happens, Azon shall not bear any legal responsibility.

I agree*

My Identity Card No. (Example: 801205069657)*

ReCaptcha

Thank you for your support!

If you have any further questions, please do not hesitate to contact us.

E-03-22 IOI Boulevard, Jalan Kenari 5, Bandar Puchong Jaya, 47100 Puchong, Selangor, Malaysia.
Mobile No: 019 -231 7154 / 011- 1431 0558
Email: info@azon.my
Website: www.azon.my

Address

E-03-22 IOI Boulevard, Jalan Kenari 5, Bandar Puchong Jaya, 47100 Puchong, Selangor, Malaysia.

Email

info@azon.my

Telephone

Existing/Registered Client Support Hotline
+6(011) 1431 0558

Child Learning & Development Assessment/
Psychological Service Appointment Booking Hotline
+6(019) 297 1431

Service/Event Inquiry，Non-Profit/Charity & Recommendation
+6(019) 231 7154

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Version 4.5.1.2024.04

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