Educational Pre-Primary School
Application form
First school day: ______Reg. Fee _ Receipt no: ______
Particulars of Child
Surname: ______Birth names: ______
Preferred name: ______Date of birth: ______
Gender: Male Female: Religion: ______
Marital status of parents: MarriedBirth order e.g. 1st, 2nd, etc.: ______
Single
Divorced
Widow / Widower
Engaged
Other
Race: ______
Home language: ______Can he/she speak English? ______
Home address: ______Postal address: ______
______
Does child live with parents:Yes No
If not, with whom does he/she live? ______
Home Tel no: ______E-mail: ______
Current Grade: ______
Previous School’s Name: ______
Previous School’s Province and Town: ______
Distance learner travels to Loerie Land Independent Pre-Primary School:
Less than 5km
Between 5km and 10km
Between 10km and 15km
Between 15km and 20km
Between 20km and 25km
More than 25km
Particulars of parents
Father (guardian) Mother (guardian)
Name & Surname: ______
Occupation: ______
Employer: ______
Physical work address: ______
Work Tel: ______
Cell no.: ______
I.D. no. : ______
Emergency Numbers Other Than Parents
- Mr/Ms______2. Mr/Ms______
Relationship to parents: ______Relationship to parents:______
Tel no (h): ______Tel no (h): ______
Tel no (w): ______Tel no (w): ______
Cell: ______Cell: ______
Collection of Child
Particulars of persons allowed to collect the child
Name: ______
ID: ______
Cell:______
Tel (w): ______
Relationship to Child: ______
Medical History
Vaccinated (Y/N): Small pocks _____ Polio ____ Measles _____ Tuberculosis _____ DPT _____
Hep B _____
Name of Medical Aid: ______Member no: ______
Family Doctor: ______Tel no: ______
Does your child suffer from any permanent conditions e.g. allergies? ______
Is there any medical condition that you feel we should be made aware of that would affect your child’s education? If yes please state what: ______
Eating Habits
Is there any food stuffs that your child is not allowed to have? ______
Reason:______
May your child receive vitamins at school? ______
Payment of school fees
Name of person responsible for payment: ______Tel no: ______
Successful registration.
We have the right to deny your child access to the school if your school fees are not paid by the 1st of the month for the month ahead.
Please sign that you accept the conditions:
Name : ______Sign : ______Date: ______
Indemnity form
I , ______parent/ guardian of ______hereby authorize the teacher/ person in charge to administer one dosage of Paracetamol syrup to my child for treatment of fever, to apply first aid where necessary and to transport my child in case of an emergency.
I declare that the UIF, the management and staff of Loerie Land Pre-Primary School will not be liable for any claims which may arise due to the transport of my child or injuries that may occur while in the care of Loerie Land Pre-Primary School.
I understand that the staff will always put the safety of my child first, but accept that they take no responsibility for unforeseen accidents.
I inspected the playground and give my consent for my child to play on all the available apparatus.
I will give one calendar month notice to the management if I wish to withdraw my child from the school.
I allow Loerie Land Pre-Primary School to assess my child and, based on this assessment, determine whether he/she may be allowed to progress to the next grade/class.
I undertake to pay the notice month’s fees as well as any other outstanding debt owed to Loerie Land Pre-Primary School before my child leaves the school. I agree to the jurisdictions of the Magistrates court and will be liable for all attorney and client cost as well as collection fees in the event of legal steps.
I will pay my Childs school fees monthly, in advance, before the first day of the month.
I will notify Loerie Land Pre-Primary School of any change of my/ our particulars on my Childs application form.
My child may undertake all field trips organized by and accompanied by the staff of the school.
Name : ______Sign: ______Date: ______
Father/Mother/Guardian
Name: ______Sign: ______Date: ______
Loerie Land Management