Spiny Babbler

  
 

EDUCATION FOCUS FORM WK07PH09-12

 
     
  ID Assigned to participant  
     
  PHOTOGRAPHY (WEEKEND SESSIONS) ENROLLMENT FORM  
  I.  
 
Participant name
 
 
   First  Middle Last
 
           
  Email
  Phone      
 
Birth date
  Day Month Year
 
 
Country of origin
 
 
Is this your first involvement with Spiny Babbler? Yes No
       
  If not, please mention other forms of involvement.
 
   
  List similar courses attended elsewhere
 
 
  II.    
  Mother or primary guardian's name
  Email
  Phone    
 
Do you want to sign up for the program e-newsletter? Yes No
       
  Father or secondary guardian's name  
  Email
  Phone      
 
Do you want to sign up for the program e-newsletter? Yes  
No  
       
  Educational institution  
  Educational level      
 

Participant's residence:
   
 

Residence location map (attach additional sheet of paper if necessary).
 
   

 

 III.  

 

 List medical conditions that SB educators need to be aware of. Eg. diabetes, asthma,  recent Hepatitis (jaundice) occurrence, epilepsy. Please note the participant's regular  doctor/clinic's name and phone number if available.  
   
     
  In cases of conditions like asthma, show each time (in case of a young child) where mendicants  such as inhalers are kept.  

 

    
  List severe allergies that SB educators need to be aware of. Eg. food, conditions, fur.  
   
     

 

 In case the participant has severe allergies, please supply at least 2 tablets of anti-allergens  prescribed by participant's doctor.  
     
 

List behavioral specifics that educators need to be aware of. Eg. very quiet, boisterous,  hits other children, etc.

  
   
     
     
  IV.  
 
Course Code Course Title Sessions Hours
WK07PH09-12:01 Photography (weekend); 12 36
 
     
  Total fee: Rs. 9,000 (Registration Rs. 500; Material cost Rs. 3,500;  Course cost Rs. 5,000)  
     
  Please mark appropriate mode of payment below.  
 
• I enclose a check made payable to Spiny Babbler.
   
• I will pay cash. Please note that no commissions or exchange of cash other than what appears on the receipt with Spiny Babbler stamp needs take place on such transactions. Please notify Spiny Babbler immediately in case any suggestions are made for unaccounted monetary exchanges.
   
• I hereby authorize the use of my credit card.
 
Visa MasterCard Discover American Express
   
 
 
Credit card number  
   
Expiration Date  
   
Address as it appears on the credit card:  
 
   
 
 
Notes:
 1. If you need support in filling up this form,contact our education officers or the front desk.
 2. Please type or write clearly (all capitals) on the form.
 3. Note that Spiny Babbler courses are quality oriented with limited availability of seats,
 register early to assure that your seat is booked for the session.
 4. Be sure that you  keep a copy of this registration form.
 
 
Download this form in printable format.

For further information
line
Email: education@spinybabbler.org
Call 5542810, 5546725 Monday to Friday 9 to 6 except on government holidays.
Visit www.spinybabbler.org/education
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