Register for Occupational Therapy

Please complete the registration form below, so we may  help you in the best possible way. The terms and conditions can be seen and downloaded here, on a new tab

I agree with the terms and conditions*
Your email address for confirmtion*
Child 1 Last Name*
Child 1 First Name*
Child 1 Grade
Child 1 Nationality*
Child 1 Date of Birth*
Child 1 Gender*
Child 1 Email
Child 1 phone
Child 1 School
Register another child
Child 2 Last Name
Child 2 Nationality
Emergency phone*
Whose phone is this?*
Child 2 First Name
Child 2 Date of Birth
Child 2 Gender
Child 2 Email
Child 2 phone
Child 2 School
Address for Invoice*
Who lives at Invoice address*
Name for invoice*
Name for company invoice*
Family status
Child 1 Address*
Mother Title*
Mother Last Name*
Mother First Name*
Mother Email*
Mother phone*
Mother address*
We would like to know your employer's name for our statistical purposes.  We sometimes contact companies to ask for funding and it helps us to be able to show how often our services have been used.  We NEVER share names of clients or personal data and all your information is treated with complete confidentiality. 
Employer of Mother
Father title
Father Last Name*
Father First Name*
Father Email*
Father phone*
Father address*
We would like to know your employer's name for our statistical purposes.  We sometimes contact companies to ask for funding and it helps us to be able to show how often our services have been used.  We NEVER share names of clients or personal data and all your information is treated with complete confidentiality. 
Employer of Father
Name of Practitioners that you will use if known
Please tell us how you found us
Confidential notes you may wish to note now to help us
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