MANUKORIHI INTERMEDIATE SCHOOL
Manukorihi Road, Waitara 4320
Phone: 06 754 8025email:
STUDENT ENROLMENT FORM
Student's Surname
First Name
Preferred First Name
Date of BirthMale/Female
Ethnic Group (group/s which student identifies with):
New Zealand EuropeanPacific Islander Specify ………………Asian Specify………………..
New Zealand MāoriSpecify Iwi ………………………… ……………………………………
Status
NZ CitizenshipNZ ResidencyFee Paying OverseasVisa No…………………………
First Language English Māori Other ………………… Language spoken at home ………………………
Student Lives with:MotherFatherGuardian* *Specify Relationship …………………..
Name of Present School ……………………………………………………… Current Year Level ……………..
TitleFirst Name Surname
PRIMARY CONTACT
Address
Relationship Postcode Occupation
Home PhoneWork PhoneCell Phone
E mailFax
Title First NameSurname
SECONDARY CONTACT
Address
Relationship Postcode Occupation
Home PhoneWork PhoneCell Phone
E mailFax
Specify Family Circumstances/Custody Arrangements:
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
EMERGENCY CONTACT (different from Primary & Secondary contacts)
First NameSurname
Address
Home PhoneWork Phone
Cell PhoneRelationship
HEALTH
Doctor's namePhone No
Impairments:Vision: Yes NoSpeech: Yes NoHearing: Yes No
Please specify any other relevant health problems:…………………………………………………………………………….
…………………………………………………………………………………………………………………………………………
Immunisation:FullyPartlyNot
Medication:Held at school:YesNo
Can the school administer Panadol without prior contact? YesNo
Permission for the school to make decisions in case of sudden
Illness or injury of my child YesNo
Permission for my child to be assessed and treated by the School
Dental Service or any Community Health members YesNo
PASTORAL
Any general information which would help us know your child ……………………………………………………………..
…………………………………………………………………………………………………………………………………………….
Any social/learning/behaviour needs ……………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………….
CONSENTS
I give permission for the school to publish any original works / photos of my Yes No
child, along with their name, age and class in school publications.
I give permission for my child’s name and contact details to be forwarded toYesNo
potential intermediate or secondary schools my child transfers to.
Outdoor Education/Day Trips (not camping activities)
I give my permission for my child to take part in Outdoor Education / Day Trips knowing
that the school has taken all reasonable steps to ensure that all safety requirements YesNo
have been fulfilled.
I understand that a condition of enrolment is that this student undertakes to abide by the
rules of the school, especially the requirements of punctual and consistent attendance,
correct uniform and acceptable behaviour. As a parent/caregiver I will do all I can toAgree Decline
ensure that he/she complies with these conditions.
Signature of Parent/Caregiver ……………………………………………..Date ………………………………..
______
OFFICE USE ONLY: Internet Agreement House Room
Admin. Student No. NSN
SLT Meeting Dual Residence