*
Parent's Name：
Last：
- First：
*
Child's Name：
Last：
- First：
Sex：
Male
Female
*
Email：
*
Child's Date of Birth：
Year
Year
Month
Month
Date
*
Contact Info：
-
-
-
Examples：
Taiwan Landline: 02-0000-0000-space
Taiwan Mobile: space-0936-000-000
China Landline: 021-00000-0000-space
China Mobile: space-1891-0000-000
Branch to Contact：
Taipei
New Taipei
Taoyuan
Hsinchu
Taichung
Tainan
Kaohsiung
Beijing
Los Angeles
Please select a branch location
*
Please describe your primary concerns with your child's behavior or learning issues: