Therapy Registration Form

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

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Azon Allied Health & Educare Development

Therapy Registration Form

Please complete the form below to register your child for a therapy programme. Fields marked * are required.

Fields marked * are required.

Sections

1Student's Details
2Parent / Guardian's Details
3Residential Address
4Emergency Contact
5Other Details
6Parent / Guardian's Consent

0% complete

Leave this field empty

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

Please attach the student's recent colour photograph and a copy of the identity card or birth certificate.

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

Other Details

Introduced by

How did you hear about us?*

RadioMagazineInternetFriendPhoneFaxSMSEmailOthers

If other, please specify

Preferred Language for Correspondence Homework, letters and notices

ChineseEnglishBahasa MelayuOthers

Parent / Guardian's Consent

I permit my child to take part in this programme. I have read the rules and regulations and understand that Azon will make proper arrangements for participants' safety. I will not hold Azon responsible for any accident occurring during the programme.

I agree*

My Identity Card No.*

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

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

Certificates and Licenses

Version 4.5.1.2024.04

Azon 20th Anniversary

About Us

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Therapy Registration Form

Student's Details

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