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______________ Occu pation 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 co nditions 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