APPLICATION FOR ADMISSION TO SCHOOL 1

RIVERSIDE SECONDARY SCHOOL

2790 HLASA STREET Telephone: 058 - 7130218

PHUTHADITJHABA Fax:

Year:

Note: This form must be completed in full. All changes to be initialed or signed by parent / guardian. Completing the form does not necessarily mean that
the learner has been accepted into the school.

Grade Applied For: Highest Grade Passed Year When Grade was passed: Accession No:

Surname: Initials: Nick Name:

First Name: Other Names:

Date Of Birth: YYYY MM DD Gender: Male: Female:

Race: Identification or Passport No:

Country of Residence: Citizenship:

If SA, indicate province of residence:

Physical Address: Home Telephone:

Emergency Telephone:

City/Suburb Learner Cell:

Code: Learner Email Address:

Home Language: Preferred Language of Instruction

Boarder Yes No

Deceased Parent Mother Father Both 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 Information

Medical Aid Number: Medical Aid Name:

Medical Aid Main Member: Doctor Name:

Doctor's Address: Doctor Telephone Number:

Medical Condition:

Special Problems Requiring Counseling:

Dexterity of Learner: Right Handed Left Handed Ambidextrous Reg. Social Grant YES NO:
:
Rec. Social Grant YES NO:
:
If the learner is accepted, the following documents must be submitted to the school:

1. Copy of Immunisation Records. 2. Copy of Birth Certificate

3. Progress Report from Previous School 4. Transfer Letter from Previous School
APPLICATION FOR ADMISSION TO SCHOOL 2
Siblings

Number of other Children at this school: Position in the family (e.g first):

Please supply full names below:

Name: Grade:

Name: Grade:

Name: Grade:

Parent / Guardian Information Complete a SEPARATE parent form for each parent living at a different physical address

Title: Initials: Surname:

First Name: Gender: Male: Female:

Home Language: Race:

Identification Number: Or Passport number Account Payer: Yes No

Residential Street Address:

City/Suburb Code:

Occupation: Employer:

Surname of Spouse: First Name:

Occupation of Spouse: Learner resides with this parent/s Yes No

Spouse ID Number: Relationship to Learner:

Marital status of parent:

Correspondence Details

Title: Surname:

Postal Address:

City/Suburb Code:

Other Contact Details

Home Telephone Work Telephone

:Number : :Number :
Fax Number : Cell Number :

Spouse Work Telephone Number: Spouse Cell Number :

E-Mail Address: Spouse E-Mail Address:

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

Name of Parent / Guardian (Please Print ) :

Signature of Parent / Guardian

:

Date: ----------------/-----------------/---------------

Office use only:

1. Date: 2. Accepted: 3. Accession Number:

4. Rejected: 5. Reason for Rejection:

6. Documentation Received: 6a Immunisation Record: 6b. Birth Certificate:

6c. Progress Report from Previous School: 6d. Transfer Letter from Previous School: