cilacademy registration form - Citadel of Integrated Learning Academy

Welcome to

Center of Integrated Learning Academy, Bmuko, Abuja

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LEARNERS INFORMATION

Upload Student Photo

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Name
First
Middle
Last
Date of Birth
Address
Address Line 1
Address Line 2
City
State / Province / Region
Country
Phone
Gender
Present School
Present Class
School of interest
Class of interest
Religion
SCHOOLS ATTENDED WITH DATES

School Name
From Date
To Date
School Name
From Date
To Date
School Name
From Date
To Date
PLEDGE

I pledge to abide by all rules and regulations of the College. (Fill your name below to sign pledge)

Name
First
Last
DOCUMENTS

Upload Birth Certificate

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Upload previous class result

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How did you hear about us?
Name of Referral
Others? Please Specify
MEDICAL INFORMATION

Blood Group
Genotype
Do you have any special health problems?
If YES, please specify
CONTACT FOR MEDICAL EMERGENCY

Name
First
Last
Relationship
Telephone
Preferred Hospital in case of emergency
PARENT'S / GUARDIAN INFO

Parent Title
Select Relationship
Name
First
Last
Telephone
Email
Profession
Residential Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country
Employer
Mother Name
First
Last
Mother Occupation
Mother Email Address

CONTACT US

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Contact

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