Mindplus your school Enrolment Form

1

How many children are you enrolling today?

2

Child's Name 1 * This field is required.

First Names

Last Name

3

Child 1 pronouns

4

child 1: What is your child's date of birth?* This field is required.

Date

5

child 1 Ethnicity 1* This field is required.

6

child 1: Ethnicity 2

7

child 1: Does your child have allergies?* This field is required.

YESNO

8

Child 1: Please list allergies including severity e.g. is your child allergic to nuts if they are touched, or in the same room as nuts or if ingested.

9

Child 1: Please list allergy medicine your child will be provided with at school. Medication will be given by the teacher. Note we have a small dog that comes to school.

10

Child 1: Does your child take any medication outside of school hours? (Required for medical emergency)* This field is required.

YESNO

11

Child 1: Please list medicine and dosage

12

Child 1: Does your child have regular daily medication during school hours e.g. ADHD medication?* This field is required.

YESNO

13

Child 1: Please list medicine, dosage and time medication is to be given to your child

14

Child's Name 2 * This field is required.

First Names

Last Name

15

Child 2 pronouns

16

child 2: What is your child's date of birth?* This field is required.

Date

17

child 2 Ethnicity 1* This field is required.

18

child2: Ethnicity 2

19

Child 2: does your child have allergies?* This field is required.

YESNO

20

Child 2: Please list allergies including severity e.g. is your child allergic to nuts if they are touched, or in the same room as nuts or if ingested.

21

Child 2: Please list allergy medicine your child will be provided with at school. Medication will be given by the teacher. Note we have a small dog that comes to school.

22

Child 2: Does your child have regular daily medication during school hours e.g. ADHD medication?* This field is required.

YESNO

23

Child 2: Please list medicine, dosage and time medication is to be given to your child

24

Child 2: Does your child take any medication outside of school hours? (Required for medical emergency)* This field is required.

YESNO

25

Child 2: Please list medicine and dosage

26

Does your child live at more than one address/home?* This field is required.

YESNO

27

Address 1 (main address)* This field is required.

Street Address

Street Address Line 2

City

Postal / Zip Code

Country

28

Address 2 (if needed)

Street Address

Street Address Line 2

City

Postal / Zip Code

Country

29

Parent/Caregiver 1 name* This field is required.

30

Parent/Caregiver 1 cellphone number* This field is required.

31

Pronouns

32

Parent/Caregiver 2 name

33

Pronouns

34

Parent/Caregiver 2 cellphone number

35

Who is your family doctor? What is their phone number?* This field is required.

36

Please state the name of an emergency contact and a phone number* This field is required.

37

Please state the name of another emergency contact and a phone number* This field is required.

38

My child/ren has permission to travel a maximum of 3km from school for walks, bush visits, trips in the neighbourhood or to the playground across from school* This field is required.

YESNO

39

My/our child/ren may have their photo taken for publicity* This field is required.

yes

only if no face is in the picture

no

40

Non refundable fee

$420 per child ($100 deposit needed within 3 days of this form being filled in for space to be reserved - an invoice will be sent to you)

41

Please list any other requirements or information important for the school to know e.g. my child is vegetarian, due to religious reasons our child is not to .......

42

Please read the community code of conduct

43

I agree to the whānau code of conduct. Please sign* This field is required.

Clear

44

All information provided is true and correct. I understand that falsifying this enrolment will result in the contract being voided and my child's enrolment being terminated. I agree to enrol my child for MindPlus YourSchool at Porirua Montessori School signed

Clear