Registration - PIEX Education

Call: +61 42 288 3015 | Email: Info@piexeducation.com

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- Username*
- First Name
- Last Name
- Phone Number* Required phone number format: (###) ###-####
- E-mail*
- Password*
- Repeat Password*
- How did you hear about us?
- Other
- Address
- Emergency Details
  Emergency Details
- Name
- Relationship
- Emergency Phone Number Required phone number format: (###) ###-####
- Emergency Details 2
  Emergency Details 2
- Name 2
- Relationship 2
- Emergency Phone Number 2 Required phone number format: (###) ###-####
- I agree to receive promotional material from PIEX Education Australia P/L.*
- I give consent to the use of photo, sound and video recordings of my child(ren) for the purpose of promoting PIXE Education Australia P/L.*
- ×The maximum number of fields has been reached.
  - ×+
  - Child’s Full Name*
  - Medicare Number (Australia) / Mykid Card(Malaysia)*(eg. 1234567891)*
  - DOB
  - Name of School*
  - ×+
  - Child’s Full Name*
  - Medicare Number (Australia) / Mykid Card(Malaysia)*(eg. 1234567891)*
  - DOB
  - Name of School*
- Please list any medical conditions or allergies, and any medication the child(ren) require
- Dietary Restrictions: If your child(ren) is on a restricted diet, please indicate foods or beverages that your child(ren) should not consume