Application for Admission
Faery Glen Therapy Centre – Please complete all sections below. Once accepted, further documents will be required.
Year of application
*
Learner details
Grade applied for
*
Highest grade passed
*
Year grade was passed
*
Surname
*
First name
*
Initials
*
Nick name
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Race
*
Identification or passport number
*
Country of residence
*
Citizenship
*
If SA, province of residence
*
Address & contact
Physical address
*
City / suburb
*
Code
*
Cell telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency contact name
*
Home language
*
Preferred language of instruction
*
Deceased parent
*
Please Select
None
Mother
Father
Both
Mode of transport
*
Religion
*
Grade 1 only — pre-primary education
Please Select
None
Non-formal
Formal
Previous school
Name of previous school
*
Previous school address
*
Code
*
Province
*
Country
*
Learner medical information
Medical aid number
*
Medical aid name
*
Medical aid main member
*
Doctor name
*
Doctor's address
*
Doctor telephone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical condition(s) the school should know about
*
Dexterity of learner
*
Right handed
Left handed
Ambidextrous
Siblings at this school
Number of other children at this school
*
Learner's position in the family (e.g. first)
*
Sibling name / grade
*
Parent / guardian information
Title
*
Initials
*
Surname
*
First name
*
Gender
*
Male
Female
Race
*
Identification number or passport number
*
Residential street address
*
City / suburb
*
Code
*
Home language
*
Relationship to learner
*
Occupation
*
Employer
*
Learner resides with this parent
*
Yes
No
Account payer
*
Yes
No
Parent 2: Name and Surname
*
Marital status of parent
*
Occupation of spouse
*
Spouse ID number
*
Residential street address
*
Relationship to learner
*
Person responsible for account
Title
*
Surname
*
Postal address
*
City / suburb
*
Code
*
Home telephone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work telephone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell number
*
Please enter a valid phone number.
Format: (000) 000-0000.
e-mail address
*
example@example.com
Declaration
I hereby declare that to the best of my knowledge, the information supplied in this application is accurate and correct.
Name of parent / guardian
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I confirm the above declaration and am ready to send this application to Glen College North Riding.
Send application
Should be Empty: