STEP 3 Full Time ENROLMENT FORM

Learner Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
ID Number or Passport Number*
Gender*

MaleFemalePrefer not to sayOther
Nationality*
IF not South African please specify Visa Type
Language(s) spoken at home*
Cell Number*
Please enter a valid phone number.
Permanent Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
MEDICAL & EMERGENCY INFORMATION
Do you suffer from any medical condition/disability that may affect your studies?*

YesNo
Please specify if yes*
Medical Aid
Membership No
Family Dr
Dr Telephone Number
Please enter a valid phone number.
Medical Consent

I being the parent/legal guardian of mentioned student herby cede my power as parent/guardian to the act as in loco parentis to the director of the college or his/her representatives, should medical treatment/surgery to my child be deemed necessary. As far as Ik now, my child is physically capable of participating in the various activities and he/she is in good health and all relevant medical information is detailed in the form above.
Signature Parent 1*

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Signature Parent 2

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Parent 1*

First NameLast Name
Parent 2

First NameLast Name
Date*

DayMonthYear
Date
Date

DayMonthYear
Date

Parent/Guardian Details

Please add both Parent Details
Learner Resides*
Who is responsible for the Payment of Accounts*
Parent 1

First NameLast Name
Parent 2

First NameLast Name
Relationship
Relationship
Mobile
Mobile
Email Parent
example@example.com
Email
example@example.com
Employer
Employer
Email
example@example.com
Email
example@example.com
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.

Debit Order Consent Form

Authority and Mandate for payment instruction: Electronic and Written Mandates
Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Details
Bank Name
Account Number
Branch Code
Amount
11 Months12 Months
Account Type

Cheque AccountSavings AccountCredit AccountOther
Debit Order Date

DayMonthYear
Date
Date of Enrolment

DayMonthYear
Date
The individual payment instructions so authorized to be issued as followed: monthly.

In the event that the payment day falls on a Sunday or a recognized South African public holiday, the payment day will automatically be the preceding ordinary business day.

I / We understand that the withdrawals hereby authorized will be processed through a computerized system provided by the South African Banks and I also understand that the details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction.

Mandate I / We acknowledge that all payment instructions issued by you shall be treated by my / our abovementioned Bank as if the instructions have been issued by me / us personally.

Cancellation I / We agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund or amounts which you have withdrawn while the Authority was in force, if such amounts were legally owing to you.

Assignment I / We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.
I allow this form to collect sensitive information like my bank details. I also confirm that all information on this form is true and complete
Authorisation
The signed Authority and Mandate refers to our contract as dated on the Enrolment Form (“The Agreement”). I/We hereby authorize you to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my / our abovementioned Bank (or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations, as agreed, to in the Agreement and commencing as per agreed Date and continuing until this Authority and Mandate is terminated by me / us by giving you notice in writing of not less than 20 ordinary working days.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Learner Details

MEDICAL & EMERGENCY INFORMATION

Medical Consent

Parent/Guardian Details

Your Academic Selection

COURSE LEVEL SELECTED

Payment Details

Supporting Document Uploads

Debit Order Consent Form

Personal Information

Bank Details