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In order to serve you better we have designed this form to capture as much information as possible about your child. Please fill in all the relevant data. The information provided here will be kept in the strictest confidence.

REFERENCE NO
DATE
STUDENT PHOTO
  BASIC DEMOGRAPHIC INFORMATION
NAME OF CHILD
GENDER
PET NAME
PLACE IN FAMILY
NO. OF SIBLINGS
DATE OF BIRTH
BIRTH CERTIFICATE NO
IMMUNIZATION NO
  PARENTS INFORMATION
MOTHER’S NAME
PHONE #
ADDRESS
OCCUPATION
WORK NO
EMAIL
WORK ADDRESS
FATHER'S NAME
PHONE #
ADDRESS
OCCUPATION
WORK NO
EMAIL
WORK ADDRESS
  EMERGENCY INFORMATION
CONTACT NAME
PHONE #
RELATION TO CHILD
CONTACT NAME
PHONE #
RELATION TO CHILD
  AUTHORISED PEOPLE WHO MAY COLLECT YOUR CHILD
We will only release your child into the care of another person if you have informed us, of their details.
NAME
PHONE #
RELATION
NAME
PHONE #
RELATION
NAME
PHONE #
RELATION
NAME
PHONE #
RELATION
  EMERGENCY MEDICAL CONSENT
I hereby give consent for the institution to seek all forms of medical and/or surgical treatment and/or other medical procedures for the above named child which may be required during my absence. I agree to pay for all services provided to my child in my absence In the event that during treatment my child is injured I waive all rights to pursue legal action. This authorization shall be effective as at today’s date unless revoked by me.
  SPECIAL CONSIDERATIONS
SPECIAL EDUCATIONAL NEEDS
SPECIAL DIETARY NEEDS
FOOD ALLERGIES
DRUG ALLERGIES
A SEVERE LONG TERM MEDICAL NEED?
If you have answered yes to any of the above, you must provide further information below with supporting information.