Therapy Registration Form

The information you provide is encrypted before it is stored and is accessible only to authorised Azon staff.

Student's Details

Please follow the identity card or birth certificate.

Therapy Programme

Student's Photograph or Identity Card A recent colour photograph, or a copy of the identity card or birth certificate.

JPG, JPEG, PNG, PDF · 5 MB

Name (Chinese)

Name (English)

Birth Certificate / Identity Card No.

Date of Birth

Age

Calculated from the date of birth. You can adjust it.

Gender

MaleFemale

Birth Order Among Siblings

School / Kindergarten

Any Physical or Psychological Condition?

YesNo

Please State the Condition

Strength

Weakness

Parent / Guardian's Details

This is how we will contact you.

Name (Chinese)

Name (English)

Identity Card No.

Occupation

Contact No. e.g. 0127777888

Mobile No.

Email Address

Residential Address

Address Line 1

Address Line 2

Postcode

City

State

State / Province

Country

MalaysiaOthers

Emergency Contact

The person we will call if anything urgent happens during a session.

Name (Chinese)

Name (English)

Contact No. e.g. 0127777888

Relationship to the Student

Payment Methods1. Cash. 2. Cheque or postal order made out to Azon Allied Health & Educare Development Sdn Bhd, sent to E-03-22, IOI Boulevard, Jalan Kenari 5, Bandar Puchong Jaya, 47100 Puchong, Selangor Darul Ehsan. 3. Cash or online transfer to Public Bank A/C No: 3239049119, then WhatsApp or send us the transfer slip. Enquiries: 019-297 1431 / 011-1431 0558 · info@azon.my · www.azon.my

Any questions?

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

019-297 1431 / 011-1431 0558

info@azon.my