Printed from SinaiAcademy.co.za

2015 Enrolment Form

2015 Enrolment Form

 Email

For office use: CLASS

START DATE

Registration fee

 

 

 

 

 

 

 

Please attach a photo of your child here

                                              

B"H

The Sinai Academy

@ Chabad of the West Coast

15 Curlewis Road · Blouberg, 7441

Phone: 021-557-7560 Fax: 021-557-9522

Email- director@sinaiacademy.co.za

Web: www.sinaiacademy.co.za

 

Enrolment Application Form

Preferred Enrolment Date: _________________________

 

PARTICULARS OF PUPIL

 

Child’s Surname:

 

 

Child’s First Name:

 

 

Preferred First Name:

 

 

Child’s Hebrew Name:

 

 

Date of Birth:

 

Time of Birth (Needed for Hebrew Birthday) :

 

 

Gender:

 

 

Home Language:

 

 

Home Address:

 

                                                                                                           Postal code:

 

Home Phone:    (      )                                                   

 

 

Father’s Name:                                                                     ID:                                                              

 

Father’s Occupation:                                                Work No.:   (       )

 

Cell No.:                                          Email address:

 

 

Mother’s Name:                                                                    ID:

 

 

Mother’s Occupation:                                              Work No.:    (     )

 

Cell No.:                                         Email address:

 

 

Emergency Details:

 

Contact Name:      ______________________________  Relationship:  ____________________                                          

 

Phone:   (      ) 

Cell    :                                                   

              

 

 

 

 

Marital Status

 

      Married        Separated         Divorced  

If separated/divorced, for how long?

                  

 

Please list any conversions in the family:

(Please include copy of conversation certificate)

 

 

Has your child attended Nursery pre-school or classes before (if yes, where)?

 

 

       No      Yes – Pre-school(s):

Indicate child’s particular strengths and/or deficiencies (physical, emotional, ineffectual)

 

 

Does your child have siblings?

    

           Brother (s)                      Sister (s)

1. Name:

    Birthday:

    School:

 

2. Name

    Birthday

    School:

 

3. Name:

    Birthday

    School:

 

 

 

 

 

 

 

YES

 

NO

 

 

 

  • I agree to my child being involved in a general assessment by a registered

      therapist.

 

  • I agree to have my child photographed for personal profiles and/or

      school PR.

 

 

 

 

 

 

 

 

 

CHILD HEALTH INFORMATION

 

Emergency Transportation

 

In case of emergency, G-D forbid, I give Sinai Academy and its employees my permission to

 

have my child _________________________________________________transported to the

 

nearest doctor/dentist or hospital/clinic for emergency medical care.

 

Parent/Guardian’s signature _________________________________  Date: ______________

 _

 

 

 

 

 

Doctor Information

Doctor’s Name:

Phone: (       )

Dentist’s Name:                 

Phone: (       )

Medical Aid:                                                                  Medical Aid No.

***IMPORTANT***

 

 

 

 

Health Information

 

X if not applicable

Allergies (food, medication, environmental) and precautions, reactions and treatment:

 

 

 

Medications, food supplements, modified diet currently being administered:

 

 

 

Chronic Physical Problems:

 

 

History of diseases the child has had:

 

 

Any additional health or enrollment information you feel we should know about your child:

 

 

 

Immunization Record

 

 

YES

 

NO

 

Has your child had all the required immunizations to date?

 

 

 

 

 

** Please supply us with a copy of your child’s Immunisation Card

 

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