425 Trinity Bldg, 8th Floor Silom Soi 5

Bangrak, Bangkok 10500 THAILAND

Ph. 02-231-5388 Fax. 022315303

Date entered _________________________

Attach
passport
size photo
here

Enrollment Application
Please print all information in capital letters

Child Information

Childs name (as it appears on passport)__________________________________________________________________

(family name)
(first)
(middle)
(nickname)

Anticipated Starting Date_________________ Date of Birth__________________ Gender (circle) M / F

Nationality on Passport___________________
Date of Issue____________________

Passport Number________________________________

Date of Expiration_______________________

Type of Visa (if foreign)________________________

Expiration of Visa___________________________

Language(s) Spoken at Home___________________ ______________________ ______________________

Home Address in Thailand____________________________________________________________________
_________________________________________________________________________________________
Home Phone Number________________________

Cell Phone_________________________________

Emergency Contact (other than parent)__________________________________________________________

(first name)
(last name)
(relationship)

Doctor Information__________________________________________________________________________
(name)
(hospital)
(phone number)
Interests/Favorite Activities:___________________________________________________________________
__________________________________________________________________________________________

Educational Background
Previous School Attended
School Name____________________________________________ Language Used_____________________
Address______________________________________ City__________________ Country_________________
Dates of Attendance________________ to ________________
(month/year)
(month/year)

Days Attended per Week________________

Type of Curriculum (i.e. American, British, etc)____________________________________________________

Health Information

Does your child have any vision problems?

Yes____ No____ Not Sure____

Does your child have any hearing problems?

Yes____ No____ Not Sure____

Do you have concerns with your childs speech?

Yes____ No____ Not Sure____

Does your child have any dental problems?

Yes____ No____ Not Sure____

Does your child have any physical health limitations?

Yes____ No____ Not Sure____

Did you or your child experience any complications during birth?

Yes____ No____ Not Sure____

Has your child suffered any physical abuse?

Yes____ No____ Not Sure____

Does your child have any allergies, food or otherwise?

Yes____ No____ Not Sure____

If yes to any of the above, please explain_________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
Does your child take any regular medication?

Yes____ No____

If yes, please state any physicians instructions____________________________________________________

__________________________________________________________________________________________

Parent/Guardian Information
Mother/Father/Stepmom/Stepdad/Guardian_____________________________________________________
(family name)
(first name)
Nationality on Passport_________________________________ Native language________________________
Employer__________________________________________ Position_________________________________
Office Address______________________________________________________________________________
__________________________________________________________________________________________
Work Phone__________________________________ Mobile______________________________________
Email address_______________________________________________________________________________

Mother/Father/Stepmom/Stepdad/Guardian_____________________________________________________
(family name)
(first name)
Nationality on Passport_________________________________ Native language________________________
Employer__________________________________________ Position_________________________________
Office Address______________________________________________________________________________
__________________________________________________________________________________________
Work Phone__________________________________ Mobile______________________________________
Email address_______________________________________________________________________________
Parent/Guardian Questions:
1. What are your goals for your child during his/her early years?______________________________________
__________________________________________________________________________________________
2. What is most important to you in his/her first year at Learning Home (i.e. English, mathematics, etc)
__________________________________________________________________________________________
3. If you know already, what primary school do you intend for your child when he finishes at Learning Home?
__________________________________________________________________________________________

Summary
Marketing
How did you hear about Learning Home?
Friends/family____

Google search/website_____

Flyer_____

Banner_____

Other_____________________________________________________________________________________
What helped you choose Learning Home International (you can choose more than one)?
Tuition fee____

Curriculum/teachers____

Location____

Other_____________________________________________________________________________________

Please submit the following with this application:

1. One 3.5x4.5cm photo of your child_____

2. Copy of your childs birth certificate_____

3. Copy of both parents ID_____

4. Copy of your childs insurance policy_____

_______________________

Signature of Parents
We acknowledge that the above information is complete and true to the best of our knowledge.
Furthermore, we have read the Learning Home International Parent Handbook and agree to comply by the
rules and regulations stated within.

______________________________________
Parent/Guardian Signature

_____________________________________
Parent/Guardian Signature

_______________________
For Office Use Only
Date application received___________________

Date of Enrollment_____________________

First Day of School_________________________ Class___________________ Teacher___________________

Date of last attendance_____________________ Class___________________ Teacher___________________
Name of School Graduating Into________________________________________________________________