545 Molly Ryde Street
Garsfontein
0081
Cell: 083 632 9175
Tel: 012 348 7099
[email protected]
www.carefreekids.co.za
REGISTRATION FORM
GENERAL INFORMATION
Child’s Information
Surname:
Name:
Date of birth:
Position in family:
Previous pre-school:
Date of entering Carefree Kid’s:
Home Language:
Nationality:
Are you a SA citizen?
If not do you have a Residence permit?
(Please hand in a certified copy with your application)
PLEASE HAND IN CERTIFIED COPIES OF YOUR CHILDS BIRTH CERTIFICATE AND
IMMUNIZATION /HEALTH RECORD and a copy of your medical aid card with your
entry form.
Father’s Information
Surname:
Name:
ID Number:
Home Address:
Postal Address:
Home Telephone:
Work Telephone:
E-mail:
Occupation:
Place of employment:
Mother’s Information
Surname:
Name:
ID Number:
Home Address:
Cell:
Fax:
Postal Address:
Home telephone:
Cell:
E-mail:
Occupation:
Place of employment:
Work telephone:
Fax:
Person responsible for paying school and other fees:
Religious affiliation:
Parent’s marital status:
Emergency telephone numbers of friends or relatives:
Name:
Tel:
Relation:
Name:
Relation:
Tel:
Name:
Tel:
Relation:
Indicate on what times your child will attend school:
Half day, 5 days/week
Full day, 5 days/week
Half day, 3 days/week
Baby Centre
HISTORY OF YOUR CHILD
Pregnancy history
Birth history
Developmental Milestones
Sit:
Crawl:
Walk :
Speech:
Toilet training:
Feeding:
General health as a baby
PERSONAL DEVELOPMENT
1. Emotional
Describe your child:
General emotional state:
Level of independence at home:
Bath:
Dress:
Feeding self:
How does he behave when reprimanded?
Can he play on his own?
Does he eat and sleep well?
Does he sleep in his own room?
Powers of concentration:
2. Social
Did he settle down easily at his/her previous school?
Friends:
Consistent?
Peer group?
Leader / Follower?
Domineering?
Aggressive?
Does he prefer to play on his own?
TV?
What do you enjoy doing as a family?
3. Cognitive
Is he inquisitive?
Language: Which language?
Vocabulary
Full sentences?
Fluency of speech: What language?
Time concept?
Play preferences:
Participation in previous school / play group’s programme:
Number concept :
4. Physical
Agile/clumsy
Catch/throw a ball
Does he show any of the following: Fear of heights? Car sickness?
Is he very sensitive / not sensitive at all to: heat / cold; textures of clothing; water in his face; food with a
rough texture
Does he shy away from: Physical contact; sand play; finger-paint; any other type of activity?
5. Normative
Does he adhere to discipline?
How do you discipline him?
Perseverance:
Does he play off one parent against the other?
Are you in accord regarding discipline?
Do you have a set routine at home?
Are you consistent?
Are you lenient or rigid?
Does the child have a task at home?
6. General
What are his / her interests?
Do you have any concerns about your child which should be brought to our attention?
Anything else you would like to mention about your child or family:
Any activities that your child may not participate in:
MEDICAL INFORMATION
Child’s Information
Surname:
Name:
Date of birth:
Doctor’s Information
Doctor’s name:
Dr’s office tel no:
Medical Aid Information (Please hand in a copy of your Medical Aid card)
Name of Medical Aid:
Main Member of Medical Aid:
Medical plan:
Number:
Medical condition
Present medical problems and chronic conditions (Epilepsy, Asthma, etc)
Allergies (drugs, insect bites, food, etc). Please send any necessary medication.
Medicines taken regularly
Name: Reason: Dosage & frequency:
Name: Reason: Dosage & frequency:
Special precautions and other information:
Undergone surgery?
Sustained minor injuries?
Received psychiatric care or counseling?
Nature and date:
Has your child be inoculated against all child diseases? Please hand in a certified proof with your
application.
Consent for the school to use another doctor or paramedic in an emergency or to transport your child to the
nearest hospital if the need occur?
Signature:
I / we herewith declare that the information in this form is correct. I / we have read the terms and conditions
and understand and accept them.
I / we understand that the fees are payable monthly or in advance for 12 months of the year. We have to
send a proof of payment to [email protected]. All school fees are payable before the 3rd of the new
month and interest will be charged on late payments. I am required to give one calendar month written
notice for my deposit to go towards my last month’s school fees. My deposit will not be paid back into my
account. I will be responsible for all outstanding fees in due of notice that my child is leaving the school. I
have to give one terms written notice for aftercare. I will pay a double monthly payment at the end of
November for December and January of the next year.
Signed at PRETORIA on the ____________________ day of _____________________ 20___.
_________________
__________________
SIGNATURE (father)
SIGNATURE (mother)
____________________
SIGNATURE PRINCIPAL