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DETAILS OF PARENT(S) OR GUARDIAN(S)

Your Name Parent / Guardian 1(Required)

First Last Relationship to Learner:

Your Name Parent / Guardian 1(Required)

Identity No. / Passport No. Nationality Marital Status

Your Name Parent / Guardian 2

First Last Relationship to Learner:

Your Name Parent / Guardian 2

Identity No. / Passport No. Nationality Marital Status

Your Address(Required)

Street Address Address Line 2 City ZIP Code

Postal Address(Required)

PO BOX Address Line 2 City ZIP / Postal Code

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone - Cell(Required)

Your Phone - Work(Required)

Your Phone - Home(Required)

Date of Application(Required)

Year of admission for which application is submitted:(Required)

LEARNER DETAILS

Learner’s Full Name and Surname(Required)

First Last

Gender(Required)

Date of Birth(Required)

Child’s Current Age(Required)

Learner’s Place of Birth

Learner’s Identity No. / Passport No:(Required)

Current Grade(Required)

Learner’s Nationality(Required)

Learner’s Home Language(Required)

Previous Institution:(Required)

Learner’s Religion(Required)

Child Lives With(Required)

Intended Start Date(Required)

LEARNER 2 DETAILS - SIBLING

Learner’s Full Name and Surname

First Last

Gender

Date of Birth

Child’s Current Age

Learner’s Place of Birth

Learner’s Identity No. / Passport No:

Current Grade

Learner’s Home Language

Learner’s Nationality

Previous Institution:

Learner’s Religion

Child Lives With

Intended Start Date

LEARNER DETAIL INFORMATION

Is the learner potty trained? The learner needs to be potty trained by his/her Grade 000 year.(Required)

Yes

SIBLING - Is the learner potty trained? The learner needs to be potty trained by his/her Grade 000 year.

Yes

Has the learner been expelled, dismissed, suspended from, or refused admission to another school?(Required)

Yes

SIBLING - Has the learner been expelled, dismissed, suspended from, or refused admission to another school?

Yes

Is the child a foreign national, if yes , please specify which country.(Required)

Yes

SIBLING Is the child a foreign national, if yes , please specify which country.

Yes

Country

If the child is a foreign national does she / he have permanent residency or will a study visa be required? (For Grade R only).(Required)

Yes

Does the child have any learning difficulties. If yes, please specify.(Required)

Yes

SIBLING - Does the child have any learning difficulties. If yes, please specify.

Yes

Specify

PAYMENT OF FEES

The parents, jointly and severally, have absolute responsibility for the payment of any fees applicable to the learner attending the school. Will a third party be assisting you with the payment of fees? If yes, please complete the following:

Name(Required)

First Last Relationship to Learner

Identity No. / Passport No.(Required)

Nationality(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Work/Home(Required)

Phone Cell(Required)

Email(Required)

This form must be accompanied by the following documents.

A copy of the child’s birth certificate or passport.

A copy of the child’s latest school report (if applicable).

A copy of any professional OT, Speech Therapy or other assessment reports if relevant.

Copy of study visa or permanent residency for Grade R applicants for foreign nationals.

Copy of passport for Grade R applicants for foreign nationals.

Copies of parents’ / guardians’ ID.

File

Drop files here or

Max. file size: 64 MB.

I hereby declare that the information that I have given is true in every respect and that I have read and understood all that is contained in this form. I understand that the completion of this form does not necessarily mean that the child will be admitted to the School. I acknowledge that by signing this document I consent and authorise Headstart Preprimary to: a) contact, request and obtain information at any time from any supplier, service or credit provider (or potential credit provider) or registered credit bureau in order to assess my behaviour, profile, payment patterns, indebtedness, whereabouts, and creditworthiness and b) provide information about my behaviour, profile, payment patterns, indebtedness, whereabouts, and creditworthiness to any registered credit bureau or to any supplier, service or credit provider (or potential credit provider) seeking a trade reference regarding my dealings with Headstart Preprimary.

Parent / Guardian Name(Required)

First Last

Parent / Guardian Signature

Max. file size: 64 MB.

Date(Required)