For Office Use Only s15

YOUR BRIDGE TO INTERNATIONAL EDUCATION

International Pre-University College

FOR OFFICE USE ONLY Date of Application Bullying & Harassment Policy: Homestay Programme: Yes: No: Computer Ethics Policy Last School report: Plagiarism Policy Subject Choice: Substance Abuse Policy Code of Conduct: Search & Seizure Policy Contractual Agreement: Application Fee Paid: Certified Birth Certificate/ ID Parent(s) / Guardian ID Doc. Or Passport 1. Student Details

Proposed date of joining IPC as a student: Homestay required (Yes/No):

Homestay required (Yes/No): Surname: ID Number:

ID Number: First Name(s): Gender (Male/Female):

Gender (Male/Female): Preferred Name: Religious Denomination:

Religious Denomination: Date of Birth (dd/mm/yyyy): Citizenship:

Citizenship: Race/Ethnicity (optional): Country of Birth:

Country of Birth: Home Language: Position in Family (eldest,youngest,etc)

Position in Family (eldest, youngest, etc):

WWW.PRE-UNICOLLEGE.COM Physical Address: Bond Street Centre, Corner Bond Street and Bram Fischer Drive, Randburg, Gauteng, South Africa Postal Address: P.O. Box 102 Fontainebleau 2032

Examinations Centre ZA013 Independent Schools Association of Southern Africa

Email Address: Residential Address (including Postal Code): Postal Address(including Postal Code)

Postal Address (including Postal Code):

2. Details of Current/Previous School Name of Current/Previous School: Name of Head of School:

School Number: School Email Adress:

Physical Address of School (including Postal Code) Postal Address of School (including Postal Code)

3. Parent’s Details 3.1 Parent’s Marital Status (Tick appropriate block) Single Married Divorced Other (please specify)

3.2 Student’s Official Guardian (Tick appropriate block) Father Mother Stepfather Stepmother Other (please specify)

3.3 Student Living with (Tick appropriate block) Father Mother Stepfather Stepmother Other (please specify)

3.4 Father’s Details Surname: Title:

First Name(s): Employer:

Preferred Name: Occupation:

ID Number: Work Tel Number:

Home Tel Number: Work Fax Number:

Cell Number: Email Address:

Residential Address (including postal code) Postal Address (including postal code)

3.5 Mother’s Details Surname: Title:

First Name(s): Employer: Preferred Name: Occupation:

ID Number: Work Tel Number:

Home Tel Number Work Fax Number

Cell Number: Email Address

Residential Address (including postal code) Postal Address (including postal code)

3.6 Details of Person Responsible for paying IPC and CIE Account Surname: Title:

First Name(s): Employer:

Preferred Name: Occupation

ID Number: Work Tel Number:

Home Tel Number: Work Fax Number:

Cell Number: Email Adress:

Residential Address (including Postal code) Postal Address (including Postal code)

4. References Name, address and telephone numbers of two persons to whom references can be made: Reference 1: Reference 2:

5. Medical Aid Details Name of Medical Aid Fund: Medical Aid Number:

WWW.PRE-UNICOLLEGE.COM Physical Address: Bond Street Centre, Corner Bond Street and Bram Fischer Drive, Randburg, Gauteng, South Africa Postal Address: P.O. Box 102 Fontainebleau 2032

Examinations Centre ZA013 Independent Schools Association of Southern Africa

Name of Student’s Medical Doctor: Telephone Number of Medical Doctor:

5.1 Does the student suffer from any health problems, any allergies, or have any learning disabilities or physical/learning handicaps? If “YES”, please provide details and enclose copies of relevant reports.

Yes: No:

5.2 Contact Person’s Details (in case of emergency) Name and Surname; Relation to Student:

Telephone Number: Email Address:

Cell Number:

6. Where did you hear about IPC? State the name and contact details of the person who referred you, if applicable.

7. Declaration of Parents or Legal Guardian (where appropriate) and Student

We undertake to pay all IPC and CIE fees in advance, and in the event of withdrawing the student form IPC, for any reason whatsoever, we undertake to give at least three months notice or alternatively, to pay three months fees in lieu of notice.

IPC expects parents, guardians and students to abide by all the IPC policies and rules and co-operate with IPC’s management, lecturers and administrators. By signing this application form, parents or guardians empower the IPC Principal to act on their behalf in emergencies.

Signature of both parents or guardian and student:

Father: ______Date: ______

Mother: ______Date: ______

Guardian: ______Date: ______Student: ______Date: ______

Please enclose the following documents, attached to your application form:

 A copy of the student’s latest school report.

 A certified copy of the birth certificate, ID document or passport.

Please note:

A non refundable application fee of R1300 is payable upon submission of this form. Please send proof of payment to [email protected] OR fax to +27 11 7923922

WWW.PRE-UNICOLLEGE.COM Physical Address: Bond Street Centre, Corner Bond Street and Bram Fischer Drive, Randburg, Gauteng, South Africa Postal Address: P.O. Box 102 Fontainebleau 2032

Examinations Centre ZA013 Independent Schools Association of Southern Africa