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*


Preferred Phone*

Child Information

First Name*

Last Name*

 Male Female


Date of Birth *

Seeking admission for *


Year Applying for*

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


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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