119 1
st
Road, Linbro Park, Sandton, Gauteng, SOUTH AFRICA
P.O. Box 119, Linbro Park, 2065, Gauteng, SOUTH AFRICA
Telephone:
(+27) 11-608-1584 / 2206
Fax:
(+27) 11-608-1586
e-mail:
modmont@global.co.za
web site:
http://www.montessoriint.com
2027 ONLINE COURSE APPLICATION FORM
The applicant and the applicant's parent/guardian (when the applicant is under 21 years old) is/are required to complete the application form and submit it to The College, together with the admission documentation detailed in the checklist to follow.
In order to facilitate the efficient processing of applications, applicants may email a scanned copy of the application form and admission documentation to modmont@global.co.za; however, the original copy of the application form must be submitted upon acceptance.
Please print clearly.
Please do not leave any of the fields blank. If there are any fields that do not apply to you, please enter 'n/a'.
In the event that there is insufficient space for you enter the relevant details, please add the remaining information to the admission documentation.
Please ensure that the bottom right hand side of each page is initialled by the applicant and the applicant's parent/guardian (when the applicant is under 21 years old) in the space provided.
Name of Applicant:
How did you find out about The College of Modern Montessori?
Rows
() or n/a
Office Use
1. Application form signed by the applicant (and parent/guardian, if applicant is under 21)
2. Copy of the applicant's ID document
3. Copy of the ID document of the applicant's parent/guardian (if the applicant is under 21)
4. Copy of the ID document of the person responsible for payment
5. If the applicant is not a South African citizen, a copy of the applicant's passport, a copy of the passport of the applicant's parent/guardian/spouse and proof of residence is required.
6. Confirmation of payment of the deposit
7. Copy of matric certificate (or most recent transcript of grades for Grade 12 applicants)
8. Copies of certification of qualification(s)/course(s previously obtained (if any)
9. Two colour ID photographs
10. Any other pertinent supporting documentation (for example: testimonials, references, awards/accolades, curriculum vitae, education specialist assessment report)
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ONLINE COURSEAPPLICATION FORM~2027 ACADEMIC YEAR
1. Applicant's Details
Title: (✔)
Miss
Mrs
Ms.
Mr
Dr
Rev.
Prof.
Other
First Names:
Surname:
Marital Status:
Single
Married
Divorced
Widowed
Name(s) and Age(s) of Child(ren):
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Gender:(✔)
Male
Female
ID / Passport Number:
SA Resident: (✔)
Yes
No
Nationality:
Passport Number:
Race:
Religion:
Home Language:
Other Language(s):
Residential Address:
Postal Address:
Tel (Home):
Format: (000) 000-0000.
Cell:
Format: (000) 000-0000.
WhatsApp
Format: (000) 000-0000.
Primary Email:
example@example.com
Alternative Email:
example@example.com
1.1 Parent/Guardian Details (students under 21 years old) / Spouse Details (married students)
Surname:
First Name:
ID / Passport Number:
Relationship to Student
Tel (Home):
Format: (000) 000-0000.
Cell:
Format: (000) 000-0000.
Tel (Work):
Format: (000) 000-0000.
Email (Personal):
example@example.com
Email (Work):
example@example.com
Residential Address:
Postal Address:
Occupation:
Employer:
Employer's Address:
Employer's Email:
example@example.com
2027 ONLINE COURSE APPLICATION FORM
2
Initials of Applicant
& Parent/Guardian
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ONLINE COURSE APPLICATION FORM ~2027 ACADEMIC YEAR
1.2 Educational Background and Qualifications
Secondary Education
Name of School:
Matric Certificate
University Entrance Pass
Other
Year of Matriculation:
Final Result: (✔)
40% - 49%
50% - 59%
60% - 69%
70% - 79%
80% +
Untitled Matrix
Rows
Grade Achieved:
1 English
2 Afrikaans
3 Math Literacy
4
5
6
7
If applicant does not have a matric certificate, specify details (include standard achieved, subjects and grades) :
Tertiary Education (if applicable)
Please specify the tertiary education institution; course description, qualification (or standard achieved); year of study:
Other Training/Courses (if applicable)
Please specify the details of any other training undertaken. Provide a description of the training and the year of study.
Learning Difficulties/Barriers to Learning (if applicable)
In the event that you have experienced any learning difficulties in the past, please provide details:
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13.1 Professional/Working Background
Please provide a brief history of your work experience (if applicable).
13.2 Medical Information
Emergency Contact Person:
Telephone Number:
Format: (000) 000-0000.
Cell Phone Number:
Format: (000) 000-0000.
Family Doctor:
Telephone Number:
Format: (000) 000-0000.
Medical Aid Company:
Membership No:
Does the applicant/student have any allergies? If yes (✔), give details.
Yes
No
Does/has the applicant/student suffer/suffered from any illness or disability? If yes (✔), give details.
Yes
No
Is the applicant/student receiving any medical treatment or chronic medication for any condition? If yes (✔), give details.
Yes
No
Has the applicant/student suffered, or been treated for, any psychological or emotional upset? If yes (✔), give details.
If yes
No
Please specify any other relevant information pertaining to the applicant's/student's health and well-being.
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ONLINE COURSEAPPLICATION FORM~2027 ACADEMIC YEAR
2. Indemnity Form
In the case of the applicant being under 21 years old, this form must be completed by the applicant's parent/guardian.
I, ________________________________________________ acknowledge that The College of Modern Montessori
cannot accept any liability for mishap, loss or injury which may be suffered during attendance at The College, or practicum
experience, or during participation in any pre-arranged excursions, or extra-curricular activities.
I accept that all reasonable precautions will be taken to ensure the safety and welfare of each student and that I shall be
held responsible for the payment of medical and/or hospital accounts where applicable, should any injury or loss be
sustained by myself/my child. I specifically indemnify and hold The College and its staff blameless against any claims of
any nature arising out of any injury, damage or loss sustained in pursuance of the aforesaid participation.
I hereby indemnify The College of Modern Montessori in respect of all occurrences relating to the above.
Signature of Applicant/Parent/Guardian
Print Name:
Date (dd/mm/yy):
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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ONLINE COURSEAPPLICATION FORM~2027 ACADEMIC YEAR
3.
2027 Fees: R63 000.00 + $240.00 (MACTE registration fee)
- Please consult section 20 of the Prospectus for further details
3.1 Details of Person Responsible for Payment
Person responsible for payment of course fees:
Applicant
Parent/Guardian
Other
If other, please supply the following details and attach a copy of ID document:
Name
First Name
Last Name
ID / Passport Number:
Relationship to Pupil:
Home Tel:
Format: (000) 000-0000.
Cell Phone Number:
Format: (000) 000-0000.
Work Tel:
Format: (000) 000-0000.
Email Address:
example@example.com
Residential Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Postal Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation:
Name of Employer:
Employers Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employers Telephone:
Format: (000) 000-0000.
Email (w):
example@example.com
4.2 Deposit
Online Course Deposit Payable:
R 8 000.00
Amount Paid:
Payment Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payment Method:
4.3 Tuition Fees
4.3 Tuition Fees
Rows
Option Annual 1: Payment
Option Annual 1: Payment
Option Quarterly 2: Payments
Option Quarterly 2: Payments
Option Monthly 3: Payments
Option Monthly 3: Payments
Select 1 of the following payment methods: ()
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ONLINE COURSEAPPLICATION FORM~2027 ACADEMIC YEAR
5. Terms and Conditions
I, the undersigned:
Hereby certify that the information provided on this application form is true, complete and accurate.
Hereby certify that the address as completed on page 2 has been elected as my domicilium citandi et executandi. Should this address differ from the address detailed on page 6, such address will be used as the domicilium citandi et executandi.
Hereby irrevocably certify and confirm that I am responsible for payment of the course fees in accordance with the terms and conditions as set out herein and in The College of Modern Montessori Prospectus.
Have read The College of Modern Montessori Prospectus and accept enrolment at The College according to the philosophies, policies and conditions laid down therein.
Understand that The College reserves the right in its sole discretion to amend and/or alter any of the provisions of The College of Modern Montessori Prospectus.
In the event that The College is required to take any action whatsoever to enforce its rights under this agreement, I acknowledge and agree to be liable for all costs incurred by The College in so doing, including but not limited to, attorney dient costs, and collection and tracing charges and I furthermore agree to The College listing my personal details adversely with the National Credit Bureau.
Endose the deposit of R8 000.00 on the understanding that it will be refunded to me in full if the application does not result in acceptance for the course.
Understand that the deposit of R8 000.00 will not be refunded once the application has resulted in acceptance for the course and that I will be bound to pay the full course fee.
Understand that the MACTE registration fee of $240.00 (US Dollars) is due and payable within one month of commencement of the course.
Understand that failure to attend dasses and/or to submit the requisite course work and/or to achieve the minimum pass grade, for any reason whatsoever, will not reduce my liability for the full course fee, except with the written consent of The College.
Understand that course material will not, under any circumstances whatsoever, be released to students whose fees are overdue.
Are aware that annual fees are payable in advance, on or before orientation..
Are aware that quarterly fees are payable in advance, on or before the following dates:
1
st
Quarter:
1
st
March
2
nd
Quarter:
1
st
May
3
rd
Quarter:
1
st
August
4
th
Quarter:
1
st
November
Are aware that monthly fees are payable in advance, on or before the first day of each month and are payable over ten months (1
st
March - 1
st
November).
Accept that a late payment penalty fee of 10% is charged on overdue accounts.
Hold myself accountable for the prompt payment of tuition fees and for any late payment penalties added onto overdue accounts.
Understand that The College reserves the right to refuse admission to a student with outstanding fees.
Understand that fees are due irrespective of absenteeism due to illness, vacation or for any any other reason whatsoever.
Undertake to reimburse The College for any damage to School/College property that may be caused by the student.
Understand that while every reasonable effort will be made to prevent losses or damage to the student's property, The College cannot be held liable.
Name of Person Responsible for Fees:
Relationship to Student/Applicant:
Signature:
Signed at:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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ONLINE COURSEAPPLICATION FORM~2027 ACADEMIC YEAR
6. Credit Check Permission
I,
ID / Passport Number
of (physical address - please provide proof)
consent and allow The College of Modern Montessori to access my full consumer profile on the database held
by any credit bureau.
Signature:
Signed at:
Date:
-
Month
-
Day
Year
Date Picker Icon
Confidentiality Note:
This page and any accompanying documents contain confidential information
intended for a specific individual and purpose. This telecopied information is private and protected by
law. If you are not the intended recipient, you are hereby notified that any disclosure, copying or
distribution, or the taking of any action based on the contents of this information is strictly prohibited.
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