Application FormPage 1

Linden Pre-Primary & Baby Centre

APPLICATION FORM

  1. PUPIL INFORMATION

SURNAME : ______

FIRST NAMES : ______

DATE OF BIRTH: ______BOY GIRL

HOME LANGUAGE: ______

ID NUMBER: ______

Home address:______

______

______Code:______

Names of other children in the family: ______

______

YEAR STARTING: ______AGE AT THE END OF DECEMBER: ______

 FULL DAY  HALF DAY  BREAKFAST

METHOD OF PAYMENT:  Cash  Cheque  Direct deposit

11 month 12 month quarterly annual

PERSON/S RESPOSIBLE FOR COLLECTING CHILD:

Persons Name :

If you deviate from this at anytime you MUST let the school know. We will not let any child leave with a stranger!

I ______hereby do consent to the above information being true and correct should there be any changes to the above, I will immediately inform the school.

Linden Pre-Primary & Baby Centre

  1. PARENTS DETAILS

MOTHERS DETAILS:

SURNAME:
FIRST NAME:
ID NUMBER:
NAME OF EMPLOYER:
OCCUPATION:
WORK TELEPHONE:
HOME TELEPHONE:
CELL NO. E-MAIL: FAX:
MARITAL STATUS:  Married  Divorced  Separated  Widowed  Single
HOME ADDRESS:

FATHERS DETAILS:

SURNAME:
FIRST NAME:
ID NUMBER:
NAME OF EMPLOYER:
OCCUPATION:
WORK TELEPHONE:
HOME TELEPHONE:
CELL NO. E-MAIL: FAX:
MARITAL STATUS:  Married  Divorced  Separated  Widowed  Single
HOME ADDRESS:

I ______hereby do consent to the above information being true and correct should there be any changes to the above, I will immediately inform the school.

Linden Pre-Primary & Baby Centre

  1. MEDICAL INFORMATION

FULL NAME OF CHILD: ______

Name of Family Doctor: ______

Doctors telephone number: ______

Name of Dentist: ______

Dentists telephone number: ______

Medical Aid: ______

Medical Aid Number: ______

Allergies: (Please list) ______

Special Instructions or Treatment Required: ______

  1. IN CASE OF EMERGENCY (Should parent not be available)

Contact Name: ______Relationship to Applicant: ______

Phone Number: ______Cell Number: ______

PLEASE NOTE: Linden Pre-Primary School will make every attempt to contact the family doctor in the event of an emergency; however the Principal or staff of Linden Pre-Primary School reserves the right to obtain medical assistance from any medical doctor in an emergency. Resulting costs will be the sole responsibility of the Legal Guardian of the child.

I ______hereby do consent to the above information being true and correct should there be any changes to the above, I will immediately inform the school.

Linden Pre-Primary & Baby Centre

  1. DECLARATION:

In completing this form you and your husband/wife undertake to:

a) Inform the school of any change of address, telephone numbers or personal information.

b) Inform the school of any infectious disease in your home.

c) Pay the school fees set out by Linden Pre-Primary School, one (1) month in advance, by the 3rd of every month for 12 months of the year. There is no reduction in the fees should your child be absent due to illness, vacation, etc.

d) Pay the Casual fees in advance for 12 months of the year, according to the number of days requested, additional days will be added to the following months account. (Days missed may be made up within the same month.)

e) Accept Linden Pre-Primary School as a charge of my child/ren based on the Rules, Regulations and Information and we, as parents, acknowledge having a copy thereof.

  1. CONSENT AND INDEMNITY

I understand that the Management Body, Principal, staff and personnel of Linden Pre-Primary School will at all times make every endeavour to ensure the safety of each child. Whilst reasonable precautions for the safety and welfare of the child will be taken, neither they nor any persons connected to Linden Pre-Primary School will accept any liability for any claims arising from injury or any accident happening to them/ us or the child while he / she is in the care of the supervisor, and to waive and abandon any claims, which may at any time arise as aforesaid, both in my / our personal capacity, and in my/ our capacity of the parent or a legal guardian of the child, and I/ we expressly indemnify the supervisor or such person against any such claim which may arise or be instituted

I give consent to the person/s in charge of Linden Pre-Primary School, or in their absence, any other responsible person connected with Linden Pre-Primary School at any given time, to take further steps that are necessary, in the event of injury or illness of the child and thereby pledge my credit.

I give consent to the person/s in charge of Linden Pre-Primary School, or in their absence, any other responsible person connected with Linden Pre-Primary School to give the required permission and sign the necessary written consent for the child to be subjected to surgery or any other medical treatment if all attempts to locate either parent or guardian fail, provided that this will be executed on the advice, and under the supervision of the family doctor, or if he / she is not available, under the supervision and advice of a medical doctor selected by Linden Pre-Primary School.

I/We confirm and hereby indemnify Linden Pre-Primary School and all its employees and representatives and hold them free and harmless in respect of any damages and / or prejudice that I /we or the child/ren may suffer as the result of illness or injury to my / our child/ren, whilst under the control or care of Linden Pre-Primary School or where Linden Pre-Primary School is liable or responsible for such child/ren.

I ______hereby do consent to have read and understood the above information.

Linden Pre-Primary & Baby Centre

I/We agree and confirm that my/our consent given herein, shall be deemed to be irrevocable unless and until withdrawn by me/us in writing, and delivery by hand to the proprietor of Linden Pre-Primary School personally, and signed for. Furthermore the terms contained in the whole of this document shall not be capable of being amended or cancelled by mutual consent unless reduced to writing and signed by myself / ourselves and the proprietor of Linden Pre-Primary School.

I hereby give consent for my child ______to participate in the extra-mural activities of the school, including outdoor play, games, school productions, school excursions and school transport service (by foot or form of wheeled transport).

------Signature of parent / guardian ------Date

I have read the enrolment material, Rule, Regulations and Information, and agree to ensure that my child/ren will submit to the programme, academic and disciplinary regulations, and all other requirements by the management, Principal and the staff of Linden Pre-Primary School.

I ______(name of parent / guardian), do hereby acknowledge that I have read, understood and intend to abide by the Rule, Regulations and Information pertaining to the conditions of enrolment, and furthermore acknowledge that no amendments or alterations of any kind may be made to this enrolment form, should any alterations be made this contract shall become void.

______

Signature: Mother / GuardianPrint Name

______

Signature: Father / GuardianPrint Name

Signed at ______on this the ______day of ______

PLEASE NOTE: that on submission of this form to the school reception, you will be required to pay a non-refundable Registration Fee.

I ______hereby do consent to have read and understood the above information.

______SIGNATURE NAME DATE

42 Second Street, Linden, Johannesburg

Tel: 011 888 2875 Cell: 082 822 8090 e-mail: web:

CK 2012 / 027848 / 07