2018 Information Form

1 Rosebank primary School 2018 Information form SCHOOL DETAILS: Gauteng registration (EMIS) number: 700151456 Type of School: Sectional 21 DATE OF APPLICATION: _____ GRADE APPLYING FOR: _____ DETAILS OF LEARNER: Gender (Boy or Girl): _____ Date of Birth: _____ Surname: _____ First Names: _____ Identity Number: _____ Nationality: _____ Home Language: _____ Passport Number: _____ Name of Previous School: _____ Tel No of Previous School:_____ Address of Previous School: _____ Fax No of Previous School: _____ First Additional Language Choice (Grade 4 7 only): _____ (Afrikaans or Zulu) SIBLING Information : (cousins are not siblings) Name of Brother/Sister at Rosebank: _____ Grade: _____ Sports House: _____ ADDITIONAL Information : Deceased parent: Mother: _____ Father: _____ Both: _____ With whom does your child reside (parents, mother, father, grandparent, guardian)? _____ Mode of Transport: _____ ( Taxi, Public, Private, Walk) Any Information that you feel the school should be made aware of?

2 _____ _____ FOR OFFICE USE ONLY: Family Number: _____ Copy of s: _____ Admission Number: _____ Work in Area: _____ Sports House: _____ Live in Area: _____ LAF Paid: _____ Birth Certificate: _____ General Comments: _____ Immunisation Card: _____ _____ School Report: _____ _____ Proof of Income: _____ _____ GDE ONLINE NUMBER GR 1 _____ FATHER/GUARDIAN DETAILS: Surname: _____ First Names: _____ ID Number: _____ Title: _____ Nationality: _____ Marital Status: _____ Home Tel Number: _____ Cell Number: _____ Home Address: _____ Postal Address: _____ Employer: _____ Occupation: _____ Work Address: _____ Work Tel Number: _____ Work Fax Number: _____ E-Mail Address: _____ MOTHER/GUARDIAN DETAILS: Surname: _____ First Names: _____ ID Number: _____ Title: _____ Nationality: _____ Marital Status: _____ Home Tel Number: _____ Cell Number: _____ Home Address: _____ Postal Address: _____ Employer: _____ Occupation: _____ Work Address: _____ Work Tel Number: _____ Work Fax Number: _____ E-Mail Address: _____ MEDICAL AID Information : Name of Medical Aid: _____ Medical Aid Number: _____ Main Member s Initials & Surname: _____ Allergies and/or Medical Problems: _____ In the event of hospitalisation, please indicate whether Private or Provincial Hospital: _____ DOCTOR S Information : Family Doctor s Name: _____ Telephone Number: _____ NEXT OF KIN / RELATIVE S DETAILS: (Other than Parent or Guardian) Surname: _____ First Names: _____ Relationship to Learner: _____ Telephone Number: _____ Address: _____ PAYMENT OF SCHOOL FEES: Rosebank primary School is a Sectional 21 school which is a fee paying school.

3 Consequently, parents / guardians are legally bound to pay school fees. Should a family renege on its responsibility to pay school fees, they can be blacklisted or have legal action taken against them by Rosebank primary School. Please note that both parents are responsible for the payment of school fees. I understand and accept the school fee responsibilities: Name: _____ Signature: _____ Date: _____ Please note that if you are placed onto Waiting List A or B, there is no guarantee of acceptance of your application.