Kiddies Ark Registration Form

KIDDIES ARK REGISTRATION FORM FAX TO: +27 11 826 3274 PARTICULARS OF CHILD 1. SURNAME FOR OFFICE USE ONLY 2. FULL NAMES DATE 3. FIRST NAME REG FEE PAID YES NO 4. HOME ADDRESS FAMILY NO CODE ADMISSION NO 5. HOME LANGUAGE ADMISSION DATE 6. GENDER (X ONLY) MALE FEMALE FULL DAY 7. DATE OF BIRTH 8. I.D. NUMBER HALF DAY 9. TELEPHONE NO. (HOME) AFTERCARE 10. MARK ONE OF FOLLOWING YOUNGEST OLDEST MIDDLE BABY 11. AGES OF OTHER CHILDREN TRANSPORT YES NO 12. RELIGIOUS DOMINATION CLASS GROUP 13. DOCTOR’S NAME CONTROL SIGN DOCTOR’S TEL. NO. 14. MEDICAL AID NAME COMMENTS / INFO UPDATE MEDICAL AID NUMBER MAIN MEMBER’S NAME 15. CONDITIONS / PROBLEMS ALLERGIES YES NO ASTHMA YES NO EPILEPSY YES NO EYES YES NO SPEECH YES NO OTHER YES NO 16. NURSERY SCHOOL OR AFTERCARE ATTENDED YES BEFORE NO 18. MARITAL STATUS SINGLE MARIED SEPERATED DIVORCED

PARTICULARS OF PARENTS / GUARDIAN MOTHER FATHER SURNAME SURNAME FULL NAMES FULL NAMES FIRST NAME FIRST NAME CELL PHONE NO. CELL PHONE NO. I.D. NUMBER I.D. NUMBER OCCUPATION OCCUPATION TELEPHONE NO.(WORK) TELEPHONE NO. (WORK) COMPANY NAME COMPANY NAME COMPANY ADRESS COMPANY ADRESS

PARTICULARS OF RELATIVES / NEXT OF KIN / FRIEND 1. NAME & SURNAME 1. NAME & SURNAME RELATIONSHIP RELATIONSHIP TEL. NO. (HOME) TEL. NO. (HOME) TEL. NO. (WORK) TEL. NO. (WORK) CELL PHONE NO. CELL PHONE NO.

I, ______(FULL NAME & SURNAME), PARENT / GUARDIAN OF THE ABOVE ENROLLED CHILD HEREBY UNDERTAKE TO PAY THE MONTHLY FEE IN ADVANCE AS DETERMINED BY THE MANAGEMENT OF KIDDIES ARK AND TO SUBMIT TO THE RULES AND REGULATIONS OF THE SCHOOL OF WHICH A COPY WAS GIVEN TO ME. I ALSO UNDERTAKE TO GIVE ONE MONTH’S WRITTEN NOTICE SHOULD I WISH TO TAKE MY CHILD OUT OF THE SCHOOL.

SIGNED DATE