Online Enrollment Please enable JavaScript in your browser to complete this form. Enrolling For: *ToddlerNurseryKinder 1Kinder 2Grade 1Grade 2Grade 3Grade 4Grade 5Grade 6OtherOther Program:Example: Tutorial, Taekwondo, Voice Lessons.Old or New Student *Old StudentNew StudentChild's Name: *FirstMiddleLastChild's Gender *MaleFemaleCitizenship: *i.e. Filipino, American, Chinese.Address: *Home Phone Number: *Birthplace: *Date of Birth: *Any Medical Conditions:i.e. Allergies, Asthma, Regular nose bleeds.Toilet Trained *YesNoAny history of communicable disease? *YesNoIf YES, what disease?Any confidential information that the School should be aware of (related to school, family and others):Person to contact in case of emergency: *Contact Number: *Father's Name:FirstMiddleLastNationality:Mobile Number:EmailOccupation:Company Name:Company Address:Mother's Name:FirstMiddleLastNationality:Religion:Mobile Number:EmailOccupation:Company Name:Company Address:Guardian's NameFirstMiddleLastRelationship to child:Contact Number:Address:Should my child suffer an injury or illness while in the care of BRILLIANT JUNIORS ACADEMY, and the facility is unable to contact me (us) immediately, I hereby authorize BJA to secure medical attention and care for my child as necessary. I (we) shall assume responsibility for payment of such services. *AgreeSubmit