Date of Application:* Entering date:*
Name of Student: *
Grade Requested: G- Last grade attended:
D.O.B:*
Nationality/Passport:*
Child’s Favorite Activities, Hobbies etc.:
Disclose fully any special health, physical, behavoural or learning problems, of which we should be aware:
Medical Notes:*
Allergies:*
Immunization shots – up to date: NoYes
Learning difficulties: NoYes
If yes, please give details:
Has your child had any special assessment, tutoring, or any form of remedial intervention in the last two years? If so, please present pertinent reports.
Difficulty with: NOYes
Religious Affiliation:
Previous School(s) attended:
Reason for leaving:
Are all fees pertaining to previous school settled in full? NoYes
Mother’s Name:*
Occupation:
Tel Home: Work:*
Cell:*
E-mail:*
Address:*
Father’s Name:*
Custodial Parent (mother,/father or both):*
Emergency/Contact Tracing Phone Numbers:*
Pediatrician Name & Number:*
Person(s) other than yourself who may collect or drop off your child:
Name(s):*
Tel(s):*
Vehicle Registration(s) (License Plates):*
all fields with the red asterisk * are mandatory
Name (required):
Phone:
Email (required):
Subject:
Message: