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

  1. 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