Middleton Pre-School by EtonHouse Surabaya

Bukit Telaga Golf TG1/10-11 Citraland, West Surabaya Indonesia

Tel: +62-31-5116 0020 +62-31-5116 0021 │ Fax: +62-31-5116 0022 │ enquiry.sby@middleton.sch.id
www.middleton.sch.id
Registration Form – Play and Stay & Play and Learn

Child’s Name: Chinese name (if applicable): Male Female

Surname / Family Name First Name
Date of Birth: / / (dd/mm/yy) Place of Birth:
Home address: __
Father Mother Child
Parent’s Name : __
Nationality : ___ __ ___
Passport (Country of Issue) : __ __ __
Passport number : ___ __ _
KTP/Kitas : ___ __
Parent’s Occupation : ___ __
Parent’s Company Name : ___ __
Parent’s Company Address : ___
To which address should correspondence/bills be sent? Home Business
Contact Details: Father Mother
Telephone (Office) : ___
Email Address (Office) : ___
Mobile : ___
Photo
Telephone (Home) : ___
Email Address (Personal) : ___
Emergency contact details:
If you cannot be reached in the case of emergency or cannot collect your child on a normal day, the following person is authorized to act on our behalf:

Name/Contact: Relationship to child:

IMPORTANT: Should Middleton be unable to contact me/us or Emergency contact person, I/we give my permission to Middleton to seek medical assistance for my child. I will bear full financial
responsibility for any cost incurred. Acknowledged by:

Which session are you interested to register your child into? □ Monday & Wednesday from 08:00 A.M. to 09:30 A.M.
*Subject to availability and first come first serve basis □ Monday & Wednesday from 10:00 A.M. to 11:30 A.M.
□ Tuesday & Thursday from 08:00 A.M. to 09:30 A.M.
□ Tuesday & Thursday from 10:00 A.M. to 11:30 A.M.