Passport Image

Birth Certificate

First Name(required)

Middle Name(required)

Last Name(required)

Preferred Name

Select Gender
MaleFemale

Date of Birth (required)

Place of Birth (required)

State of Origin(required)

Home Address (required)

Previous School Attended

First Name(required)

Last Name(required)

Personal Email

Select Parent 1 Gender
MaleFemale

Relation to Student(required)
—Please choose an option—FatherMotherGuardianother

Occupation

Employer

Mobile Phone

First Name(required)

Last Name(required)

Personal Email

Select Parent 2 Gender
MaleFemale

Relation to Student
—Please choose an option—FatherMotherGuardianother

Occupation

Employer

Mobile Phone

Name(required)

Address(required)

Mobile Phone(required)

HMO

HMO No

Hospital

Does your child have any medical concerns i.e Allergies, Asthma, Medication?

High feversFood allergiesSerious injuriesSeizures/ convulsionsEnvironmental allergiesHeadaches/ dizzinessMeningitisAsthmaSleeping difficultyVision problemsOn-going MedicationOn-going feeding/eating/choking/drooling problemsHearing problemAnaphylaxis Triggers

Medical Diagnosis

Family Doctor

Pedeatrician

Does This Student Need a School Bus
YesNo

Full Name Of Who Will Pick Up Your Child

Personal Email Of Who Will Pick Up Your Child

Phone Number Of Who Will Pick Up Your Child

Passport Image Of Who Will Pick Up Your Child