Admission form – St. Samuel International School

- Step 1 of 4

STUDENT INFORMATION

Name *

First

Middle

Last

Gender

Male
Female

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Phone

Religion

Number of Brothers

Number of Sisters

Nationality

Name of Previous School

Class in Previous School

Parent

Choose *

Parent(Father and/or Mother)
Guardian

Name of Mother

First

Middle

Last

Name of Father (copy)

First

Middle

Last

Name of Guardian

First

Middle

Last

OCCUPATION

Address

Address Line 1

Address Line 2

City

State / Province / Region

PLACE OF EMPLOYMENT

Phone Number

Email *

RELIGION

NATIONALITY

HEALTH HISTORY

Does your child have any eye problems? If yes specify

Does your child have any allergies? If yes, please state what kind of allergies

Does your child have any physical/dietary constraints? If yes, please specify

Other health problem (e.g. Diabetes, Seizure, Seizure, Sickle Cell Anemia, Worm Infestation etc.) that must be known to the School (Please Give Details)

Is your child fix to participate in all sporting activities? If No, please state why

Does your child have any specific problems/ fears/ needs? Please explain

Does your child have any specific problems/ fears/ needs? Please explain (copy)

MEDICAL CONTACT

Please provide the following information in event a Medical Emergency.

Name of Doctor *

First

Last

Phone

Address

Address Line 1

City

State / Province / Region

EMERGENCY INFORMATION

(Emergency contacts other than parents/Guardians)

Name *

First

Last

RELATION

Phone Number

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

I hereby give my consent to the school for all emergency medical care/first aid treatment for my child while my child is in the custody of the school. I shall bear expenses against such service

Name *

First

Last

Date / Time

Date

Time

PICK-UP AUTHORIZATION

Upon my inability to pick up my child at the close of day I authorize that my child be released to either of the following persons. (Attach passport size photographs of each person, please)

Name *

First

Last

Phone Number

Address

Address Line 1

City

State / Province / Region

Upload a Passports Picture

Click or drag a file to this area to upload.

Declaration

I hereby declare that the Parent/ Guardian of the child named above and I am fully responsible for the payment of his/her fees and other related charges. I agree that fees are to be paid in full and at the beginning of the term and that fees once pain are not refundable. I agree that a term’s written notice (i.e. three months) is to be given prior to the withdrawal of my child from the school or a term’s fess must be pain in thereof.

Name *

First

Last

Date / Time

Date

Time