Applications

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select school:

Grade applying for

Accession

Surname

learner first Name

Other names

Initials

Nick name

Date of birth

Gender : Male female

ID or Passport No:

Race :
African White Colored Indian Other

Country of Residence

Citizenship :

If SA,indicate province of residence:

physical address:

City/suburb:

Code:

cellno

Home telephone:

Emergency telephone:

Home language

Preferred Language of instruction

Boarder :
Yes No

deceased parents
mother father both none

Mode of transport

Religion

for Grade 1 only:Indicate pre-primary education:
None Non formal formal

Previous school information

Name of previous school

Previous school address

code

Province:

Country:

Learner medical info

Medical Aid number:

Medical Aid name:

Medical Aid main member:

Doctor name:

Doctor's address:

Doctor's telephone:

Medical condition:

Special problems requiring counsellling:

Dexterity of learner

Reg. social Grant: Yes No

Rec. social Grant: Yes No

Siblings

number of other children at this school

position in the family(eg first):

Please supply full names below:

Name: Grade:

Parent/Guardian information

title:

Initials:

Surname:

First name:

gender:
Male female

Home Language

Race
African White Colored Indian Other

Identification number:

Account payer:
Yes
No

Residential address:

City/suburb:

Code:

Occupation:

Employer:

Spouse Surname:

Spouse First Name:

Occupation of spouse:

Learner resides with this parent:
Yes
No

Spouse ID:

relationship to learner:

Marital status of parent:

Correspondence Details

title:

Surname:

Postal Address:

City/suburb:

Code:

Other Contact Details

Home telephone:

work telephone:

Fax no:

Cell no:

Spouse Cell no:

Spouse work telephone:

email:

Spouse email:

Attachments

document

I hereby declare that to the best of my knowledge,the above information as supplied is accurate and correct.