SHOP - Edu Skills Centre for Learning

CHILDS DETAILS

First Name *

Last Name *

Date of Birth *

ID Number *

Grade at Entry *

Age at Entry *

Gender *MaleFemal

Homeschooling Curriculum Chosen *UCT Online High SchoolMos-WêreldwydAuxilioBrainlineImpaqTHINK Digital CollegeKoa AcademyASDANHomework Care

FATHER / GUARDIAN DETAILS

First Name *

Last Name *

Date of Birth *

ID Number *

Phone *

Email Address *

Street Address *

City *

ZIP / Postal Code *

MOTHER / GUARDIAN DETAILS

First Name *

Last Name *

Date of Birth *

ID Number *

Phone *

Email Address *

Street Address *

City *

ZIP / Postal Code *

MEDICAL AND HEALTH

Does your child take regular medication? *YesNo

If yes, please specify *

Are there any special medical, physical or emotional needs that the centre should be aware of? *YesNo

If yes, please specify *

Is your child potty trained? *YesNo

In the event your child is ill or injured and we cannot get hold of you we will take your child to the local doctor? You will be liable for all the associated charges *Yes

BILLING INFORMATION

Person responsible for payment of fees (NB: The parents are ultimately responsible for payment of the fees, even if somebody else has undertaken to pay them and defaults)

Is person responsible for payment of fees different from parents /guardian? *YesNo

First Name *

Last Name *

Date of Birth *

ID Number *

Phone *

Email Address *

Street Address *

City *

ZIP / Postal Code *

SIGNATURES

PARENTS / GUARDIAN

First Name *

Last Name

Signature

ID Number *

Date Signed *

Monthly Payment

CHILDS DETAILS

FATHER / GUARDIAN DETAILS

MOTHER / GUARDIAN DETAILS

MEDICAL AND HEALTH

BILLING INFORMATION

Person responsible for payment of fees (NB: The parents are ultimately responsible for payment of the fees, even if somebody else has undertaken to pay them and defaults)

SIGNATURES

PARENTS / GUARDIAN