Course Enrollment Form

This form is used to collect student details for enrolling in academic courses or training programs. Please fill in all the required fields thoroughly to ensure successful enrollment.

Student Information

Full Name: {firstName} {lastName}

Date of Birth: {dateOfBirth}

Gender: {gender}

Email Address: {email}

Phone Number: {phoneNumber}

Address: {address}

Enrollment Details

Course Title: {courseTitle}

Program Type: {programType}

Start Date: {startDate}

End Date: {endDate}

Enrollment Date: {enrollmentDate}

Guardian/Parent Details

{^isAdult} Name: {guardianName}
Contact Number: {guardianContact}
Relationship to Student: {guardianRelation} {/isAdult}

Previous Education (if applicable)

{#previousEducation}

• Institution: {institutionName}, Degree: {degree}, Year: {yearCompleted}

{/previousEducation}

Selected Modules

{#selectedModules}

• {moduleCode}: {moduleTitle}

{/selectedModules}

Emergency Contact

Name: {emergencyName}

Relationship: {emergencyRelation}

Phone Number: {emergencyPhone}

Email (optional): {emergencyEmail}

Additional Notes

{additionalNotes}

Required Documents

{#documents}

• {documentName}

{/documents}

Payment Information

Tuition Fee: {tuitionFee}

Payment Method: {paymentMethod}

Payment Date: {paymentDate}

Payment Reference: {paymentReference}

Declaration

I, {firstName} {lastName}, confirm that the information provided above is true and accurate to the best of my knowledge. I agree to the course enrollment terms and conditions.

Signature: ____________________________

Date: {declarationDate}