Parent Information

First Name*

Last Name*

Your Email*

 

How did you hear about Explorika*

Mailing Address*

Your Relationship with the child*
 Father Mother Guardian

 

Area Name*

City*

Preferred Phone*

Child Information

First Name*

Last Name*

Gender*
 Male Female

 

Date of Birth *

Seeking admission for *

 

Year Applying for*

Does your child have any Special Educational Needs?*
 Yes No

Others

Preferred day for campus visit*

Preferred time for campus visit*

 

Relationship Manager in contact with*

Company (Select only if Tie-up with Explorika exists) *

 

Additional Comments

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