Shirley Intermediate School
Enrolment Form
| STUDENT’S FULL NAME: Student’s mobile phone number:(Last name) (First names – underline preferred name) | |||
| GENDER: MALE FEMALE DATE OF BIRTH: ______ /______ /_____ | |||
| STUDENT’S ADDRESS: _________________________________________________ (Suburb) ____________________________________ (Area Code) _____________ | |||
| PREVIOUS SCHOOL: _______________________________________ __________________________Name of School City/Town | |||
| CAREGIVER( 1 )NAME : Mr/Mrs/Ms/Miss ____________________ ADDRESS: ______________________________________________________
TELEPHONE:_______________ MOBILE:______________________________ E-MAIL__________________________Caregiver/Mother/Father |
OCCUPATION: ___________________________________PLACE OF WORK:__________________________________
TELEPHONE:_____________________________ Legal Guardian Yes/No |
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| CAREGIVER( 2 ) NAME : Mr/Mrs/Ms/MissADDRESS:TELEPHONE: MOBILE:
E-MAIL: Caregiver/Mother/Father |
OCCUPATION:PLACE OF WORK:TELEPHONE:
Legal Guardian Yes/No |
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| EMERGENCY CONTACT NAME :Mr/Mrs/Ms/MissFirst Name: __________________ Surname:_________________ ADDRESS:
Relationship to student? |
TELEPHONE: (home) ____________________________TELEPHONE: (work)
_____________________________ MOBILE: (an emergency contact must have a phone number) |
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| DOCTOR’S NAME: TELEPHONE:(Please include initials) | |||
| MEDICAL PROBLEMS: YES NOIf YES, please state: | |||
NEW ZEALAND OTHER (please state) ___________________________ DATE OF ARRIVAL IN NZ ______________ * Please attach a copy of the student’s birth certificate or passport to this form,
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| ETHNIC GROUP: NZ EUROPEAN OTHER (please state) _________________________ MAORI (please fill in iwi affiliation overleaf) | |||
| IWI AFFILIATION:If the student is of New Zealand Maori descent please enter the name(s) of his/her iwi.You may enter more than one iwi. If you do not know the iwi, please enter ‘Don’t Know’.
Please place student in Te Taahu Rua Reo class YES / NO |
Iwi: _______________________________________________ Rohe (Iwi home area): ________________________________Iwi: _______________________________________________ Rohe (Iwi home area): ________________________________Iwi: _______________________________________________ Rohe (Iwi home area): ________________________________ |
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| WHAT IS THE MAIN LANGUAGE SPOKEN AT HOME: ENGLISH OTHER (please state) ____________WOULD YOU LIKE ASSISTANCE WITH ESOL (English for Speakers of Other Languages): YES / NO |
| DOES YOUR CHILD HAVE LEARNING AND/OR BEHAVIOUR NEEDS: YES / NO__________________________________________________ (Staff note: Please refer to a senior staff member if required) |
| DOES YOUR CHILD HAVE A SISTER/BROTHER AT THIS SCHOOL? YES / NOIf YES, please complete details:NAME _______________________________________ ROOM ___________ |
| PLEASE LIST YOUR CHILD’S HOBBIES/INTERESTS/SPORTS AND/OR CLUBS:_________________________________________________________________________________________________ |
| Agreement of SupportInformation and Privacy
I/We agree that this and any other information collected may be used for educational purposes and in the best interests of the student named above. I/We understand that all such information will be held at Shirley Intermediate School where we shall have the right to view all records. I/We have an obligation to inform the school of any change to the personal details about this student. Medical Assistance I/We agree that should the School be unable to contact either me/us or other emergency contacts as listed in the School records, the School may seek on my/our behalf any medical assistance which might reasonably be required to assure good health and safety. I/We shall reimburse any costs to the school in seeking such assistance. I/We agree that the School may offer simple routine medication to alleviate minor symptoms by my/our child in the sickbay. This might include the controlled use of Panadol in some circumstances. School Rules I/We agree to abide by the School’s policies and regulations and we support School Mission Statement which is “Together we show respect for ourselves and others and always do our personal best.” I/We agree to take responsibility for the payment of replacement or repair of School property which my/our child has damaged. Publications I/We agree to allow the School to publish my/our child’s work and photographs in School related publications. Signed:__________________________________ __________________ Caregiver 1 Date Signed:__________________________________ __________________ Caregiver 2 Date |
**Office Use Only**
| Room | Year | Teacher | Start Date | Enrolment No | Student Manager | Library | ICT | ENROL | Weekly Roll Return |
| The information on this enrolment form is for the use of the school and may be used to provide data to other education agencies
provide data to other education agencies |
Shirley Intermediate School Principal: Geoff Siave
Cnr North Parade & Shirley Road Phone: (+64)-03-385-2229
P O Box 27-028 Fax: (+64)-03-385-2335
| www.sis.knowledge.net.nz |
CHRISTCHURCH Email: principal@sis.school.nz