Aftercare admission form 2013.pdf - Shaun Leonard

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APPLICATION FOR ADMISSION TO AFTERCARE CENTRE CHILD’S NAME: ________________________________________________________ Date of Birth: ________________________________________________________ Name you would like child to be known as: ____________________________________ Boy/Girl _______________________________________________________________ Mother’s Name: _______________________________ Address: _______________________________ Telephone: home _____________ work _____________ cell______________ Occupation and place of employment: ______________________________________ Father’s Name: _______________________________ Address: _______________________________ Telephone: home _____________ work _____________ cell______________ Occupation and place of employment: ______________________________________ Marital Status: ________________________ EMERGENCY CONTACT AND TELEPHONE: _______________________________________ DOCTOR’S NAME AND TELEPHONE: ____________________________________________________ Is your child presently receiving aftercare? Yes / No Where? ___________________________ Does your child have allergies? __________________________________________________________ Is your child on special medication? _______________________________________________________ Appetite? (e.g. good, poor, fussy eater) _____________________________________________________ Any emotional problems or trauma child has experienced? _____________________________________ Other particulars (write any other motivation that you feel the school should know about). If such motivation is confidential please enclose in a sealed envelope marked “Confidential Aftercare” and address it to the Principal. I/We undertake to abide by the conditions of the aftercare and consent to the person/s responsible for the immediate care of my child/children acting in loco parentis. Application must be made each year for the following year in respect of each pupil _______________________________________ ________________________ SIGNATURE OF PARENT/LAWFUL GUARDIAN DATE