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Learner Particulars.pdf - FORM - Learner Particulars

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					LEARNER PARTICULARS                                                                              CONFIDENTIAL


A   Learner’s Information: (This section must be completed by the student.)

    Name:               Surname:

                        First Name(s):




    Date of Birth:                                   Gender:
    Day         Month            Year                Male             Female


    ID:


    South African Citizen:    Yes               No               Home Language:

                                                                 Other Language(s):


    Currently Residing with: (Please tick)      Father                    Mother                 Stepfather
                                                Stepmother                Guardian               Adoptive Father
                                                Adoptive Mother           Other:


    Home Address:




                                                           Postal Code:


    Postal Address:




                                                           Postal Code:


    Home Telephone:                                         Fax Number:

    Cellular Phone:                                         E-mail:




    Do you have a valid passport?        Yes          No           If yes, please complete the following:

    Passport Number:                                   Issue Date:     DD MM YYYY       Expiry Date:   DD MM YYYY




    Do you have any driver’s licences?         Yes          No            If yes, please complete the following:

    Licence types and dates issued:

    PLEASE SUBMIT A COPY OF YOUR DRIVER’S LICENCE(S) WITH YOUR APPLICATION.
Do you have any siblings?      Yes         No          If yes, please fill in their details from oldest to youngest:

Name                                                     Age     School, study, work, etc.

1.

2.

3.

4.


Briefly describe the nature of your relationships with the following people:

Each parent/guardian:




Each sibling:




Other students at your school:




Have you ever smoked cigarettes, misused alcohol, been drunk or used drugs of              Yes            No
any kind?

If yes, please clarify:




Have you ever committed a crime, been in trouble with the law or been                      Yes            No
arrested?

If yes, please clarify:




List any current or previous sporting interests, involvement or achievement in or out of school.




List any current or previous cultural or musical interests, involvement or achievement in or out of school.




List any current or previous leadership positions held in or out of school.



List any current or previous involvement in clubs, societies or community service activities in or out of school.
B Learner’s School Related Information: (This section to be complete by a parent/guardian)

   Please complete the details of the school currently being attended.

   School:                                                         Suburb/City:

   Telephone Number:                                               Principal:

   Enrolled into Grade ____ in ________ (year).

   Reason for leaving:

   Are school fees at the current school up to date?       Yes              No


   Has the student been required to attend any disciplinary hearings or received any disciplinary sanctions
   (for example, detention, community service, suspension or expulsion) at any of the schools that have been
   attended? Has the student ever been refused admission to any school?
                                                                                        Yes          No

   If yes, please clarify.




   Briefly describe the student’s general level of responsibility, independence and self-discipline, including
   with regard to the completion and presentation of homework and project work.




   Briefly describe the student’s attitude towards their personal appearance, school and school related
   activities.




C Learner’s Medical Information: (This section to be complete by a parent/guardian)

   Family Doctor:                                          Telephone Number:

   Physical Address of Practice:




   Is the learner listed as a member or dependant of a Medical Fund?              Yes                No

   If yes, please complete:

   Name of Medical Fund:                                             Membership No.

   Main Member’s Name:                                               Telephone No.
   Does the student have any allergies, physical disabilities, medical or psychological    Yes        No
   conditions?

   If yes, please give details.




   Has the student been assessed for or diagnosed with any learning difficulties or        Yes        No
   barriers, e.g. ADD, ADHD, Dyslexia, etc.?

   If yes, please give details.




   Is the student currently making use of any prescription medication?                     Yes        No


   If yes, please give details.




  List any contagious diseases, medical conditions, serious illnesses or operations the student has had.




   Has the student been assessed by or consulted with any of the following?

   Speech Therapist                Yes        No           Audiologist                    Yes        No
   Occupational Therapist          Yes        No           Psychologist                   Yes        No
   Psychiatrist                    Yes        No           Family Counsellor              Yes        No

   Other: (Please give details.)




D Parents/Guardians with whom the student resides

   Parent/Guardian #1:                                       Relationship to Student:

   First Name:                                               Surname:

   Telephone (H):                                            Cell Phone:

   Telephone (W):                                            E-mail:

   Home Address:




   Postal Address:




   Occupation:                                               Company:
    Parent/Guardian #2:                            Relationship to Student:

    First Name:                                    Surname:

    Telephone (H):                                 Cell Phone:

    Telephone (W):                                 E-mail:

    Occupation:                                    Company:



E   Additional Significant Adults

    Additional Adult #1:                           Relationship to Student:

    First Name:                                    Surname:

    Telephone (H):                                 Cell Phone:

    Telephone (W):                                 E-mail:

    Home Address:




    Postal Address:




    Occupation:                                    Company:


    Additional Adult #2:                           Relationship to Student:

    First Name:                                    Surname:

    Telephone (H):                                 Cell Phone:

    Telephone (W):                                 E-mail:

    Home Address:




    Postal Address:




    Occupation:                                    Company:



F   Transport Information

    How will the student get to and from school?
G Record of Understanding

  The undersigned declare that all information contained in this form is, to the best of their knowledge, correct.

  The undersigned accept that Keystone College has the right to verify any information contained herein.


  Name of Parent/Guardian:                                              Signature:

  Relationship to Student:                                              Date:


  Name of Parent/Guardian:                                              Signature:

  Relationship to Student:                                              Date:


  Signature of Student:                                                 Date:



H FOR OFFICIAL USE ONLY

  Grade Readiness Evaluation

  Literacy                                                                               Test Score:

  Teacher’s Assessment:




  Teacher’s Recommendation:




  Numeracy                                                                               Test Score:

  Teacher’s Assessment:




  Teacher’s Recommendation:




  School Recommendation:

				
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posted:1/25/2011
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