ATTITUDE SHINES COACHING PROGRAM

STUDENT APPLICATION FORM

Section 1: Children Information
Name :	Preferred Name:
Date of Birth: (dd/mm/yyyy)	NRIC :
Applying for : 3 months ( ), 6 months ( ), 9 months ( )
Telephone Number : Email:	Primary language/ dialect most often spoken by the student:
Mailing Address
House Full Address:
State:	City:
Postal code:	Country:
Sibling (If any) 1. 2. 3.
Section 2: Parents’/Guardians’ Information
Relationship to the students:
Name:
Career:	Office Tel:
Email :	House Tel:
Fax:	Mobile:
Office Address:
City:	Postal Code:
Section 3: Emergency Contacts
Name:	Tel:
Section 4: School Information
School Name	Class/Form:
Club joined:
Achievement (Sport) :Gold ( ), Silver ( ), Bronze ( )
Achievement (Academic): Current Class ( ) UPSR ( ) SPM ( )
Hobbies :
Talent :
Area that need improvement :

Acknowledgement of acceptance

I hereby accept ‘Attitude Shines’ Coaching Program for my child. I expect to follow the guidance and support of a professional coach to complete the program for my child.

………………………………………

(Signature) Parents / Guardian

Date: