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Milestone Online Workshop Registration Form:

Name : *

Gender : *

Male

Female

Date of Birth : *

School : *

Standard : *

Telephone Number [Landline] : *

Email id : *

Workshop Interested to enrol : *

Date of the Workshop : *

Venue : *

	Milestone Centre
	Other

Fee Amount : *

Address : *

City : *

State : *

Zip : *

Mother/Guardian's First Name and Last Name : *

Telephone Number : *

Email id : *

Father/Guardian's First Name and Last Name : *

Telephone Number : *

Email id : *

Other emergency contact number : *

Relationship : *

Telephone Number : *

Mode of Payment :

Medical Information :

I hereby state, that there is no disease / disorder / deformity which will come in way of attending the program.

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