Northern Academy Application Form – Fill Out and Use This PDF

NORTHERN ACADEMY APPLICATION FOR ADMISSION

Meridian Operations Company NPC (RF) Reg No 2012/081855/08 / NPO Reg No 116-433NPO

Campus and Property Management Company (Pty) Ltd Reg No 2012/001821/07 / VAT Reg Number 4290261926

SCHOOL APPLIED AT

NORTHERN ACADEMY

MONTH & YEAR APPLIED FOR

This Application for Admission will only be processed if ALL fields are completed legibly, are signed and ALL relevant supporting documents are attached.

Ref 2013/001

REQUIRED SUPPORTING DOCUMENTS, COMPLETED SECTIONS & FORMS

FOR OFFICE USE

SECTION 1 : LEARNER'S PERSONAL DETAILS

SURNAME

FULL NAMES AS ON BIRTH CERTIFICATE / ID DOCUMENT

HOME & OTHER SPOKEN LANGUAGE/S			HOME					OTHER
LANGUAGE/S OF LEARNING & TEACHING			FIRST					SECOND
NUMBER OF CHILDREN IN FAMILY						POSITION OF LEARNER IN FAMILY
NATIONALITY			COUNTRY OF ORIGIN					DATE OF IMMIGRATION

SECTION 2 : LEARNER'S EDUCATIONAL DETAILS

CURRENT SCHOOL				PREVIOUS SCHOOL
ADDRESS				ADDRESS
		CODE				CODE
TEL NO	CODE			TEL NO	CODE
PRINCIPAL				PRINCIPAL

LAST GRADE PASSED

YEAR

GRADE/S REPEATED

HAS ADMISSION TO ANY OTHER SCHOOL/S EVER BEEN REFUSED? IF YES, PLEASE STATE REASON.

YES

NO

REASON

ACADEMIC ACHIEVEMENTS

EXTRACURRICULAR ACHIEVEMENTS

OTHER ACHIEVEMENTS

SECTION 3 : LEARNER'S MEDICAL DETAILS

BLOOD TYPE

O+

O-

A+

A-

AB+

AB-

B+

B-

UNKNOWN

FAMILY DOCTOR

NAME

TEL NO

CODE

ADDRESS

CODE

MEDICAL AID

NAME

NUMBER

MAIN MEMBER INITIALS & SURNAME

ID NR

OPTIONS

HAS THE LEARNER RECEIVED ALL THE NECESSARY IMMUNISATIONS? IF NO, PLEASE STATE REASON.

YES

NO

REASON

HAS THE LEARNER SUFFERED FROM ANY OF THE FOLLOWING ILLNESSES? PLEASE INDICATE WITH AN X.

ASTHMA

ENTERIC FEVER

MEASLES

SCARLET FEVER

CHICKEN POX

GERMAN MEASLES

MUMPS

TICKBITE FEVER

DIABETES

HEPATITIS

POLIO

TYPHOID FEVER

DIPHTHERIA

MALARIA

RHEUMATIC FEVER

WHOOPING COUGH

DOES THE LEARNER SUFFER FROM ANY ALLERGIES?

YES

NO

IF YES, PLEASE GIVE DETAILS.

PAGE 2 OF 7

SECTION 3 : LEARNER'S MEDICAL DETAILS - CONTINUED

IF YES, PLEASE GIVE DETAILS.

PLEASE SPECIFY ANY OTHER RELEVANT MEDICAL DETAILS.

SECTION 3 : LEARNER'S MEDICAL DETAILS - CONSENT

IN A CRITICAL MEDICAL SITUATION, PLEASE BEAR IN MIND THAT THERE MAY NOT BE TIME TO REFER TO THE LEARNER'S RECORDS. THE SCHOOL THEREFORE RESERVES THE RIGHT TO UTILISE THE QUICKEST MEDICAL SERVICE AVAILABLE.

I,BEING THE PARENT / LEGAL GUARDIAN OF

HEREBY AGREE THAT A MEDICAL PRACTITIONER MAY PROVIDE EMERGENCY TREATMENT AS MAY BE NECESSARY.

SIGNATURE OF PARENT / LEGAL GUARDIAN

SECTION 4 : DETAILS OF FATHER / STEPFATHER / LEGAL GUARDIAN

COMPLETE ONLY IF NOT THE ACCOUNT HOLDER. REFER TO SECTION 8.

SURNAME

FULL NAMES AS IN ID DOCUMENT

DESIGNATION

MR

MRS

MS

MISS

DR

REV

PROF

OTHER

IDENTITY NUMBER

RELATIONSHIP

MARITAL STATUS

OCCUPATION

EMPLOYER

RESIDENTIAL ADDRESS

WORK ADDRESS

POSTAL ADDRESS

CODE

CODE

CODE

TEL H CODE

TEL W

CODE

CELL

E-MAIL ADDRESS (PLEASE WRITE LEGIBLY)

PARENTAL STATUS

LEARNER LIVING WITH

LEARNER'S LEGAL

ACCESS RIGHTS TO

ACCESS RIGHTS IN AN

PARENT/S

GUARDIAN

LEARNER

EMERGENCY ONLY

PAGE 3 OF 7

SECTION 5 : DETAILS OF MOTHER / STEPMOTHER / LEGAL GUARDIAN

COMPLETE ONLY IF NOT THE ACCOUNT HOLDER. REFER TO SECTION 8.

SURNAME

FULL NAMES AS IN ID DOCUMENT

DESIGNATION

MR

MRS

MS

MISS

DR

REV

PROF

OTHER

IDENTITY NUMBER

RELATIONSHIP

MARITAL STATUS

OCCUPATION

EMPLOYER

RESIDENTIAL ADDRESS

WORK ADDRESS

POSTAL ADDRESS

	CODE				CODE			CODE
TEL H CODE			TEL W CODE				CELL
E-MAIL ADDRESS (PLEASE WRITE LEGIBLY)

SECTION 6 : DETAILS OF ANOTHER CONTACT IN THE CASE OF AN EMERGENCY

SURNAME					FULL NAMES
RELATIONSHIP
TEL H CODE			TEL W CODE			CELL
E-MAIL ADDRESS (PLEASE WRITE LEGIBLY)

SECTION 7 : DECLARATION OF PARENTS / LEGAL GUARDIANS

We the undersigned, _________________________________________________________________, hereby certify that the information given by us

in this Application for Admission is complete and accurate. We also agree to the conditions as set out herein.

We accept that the School is based on Christian principles and undertake that this will not be undermined.

We understand that the prescribed number of learners per class may be exceeded through the placing of a current learner that has to repeat a grade.

This Application for Admission will be reconsidered in the case where important relevant information, which should be brought to the School’s attention, is withheld.

We have read the Code of Conduct, Substance Abuse Policy and Dress Code and will accept an offer of placement for our child at the School in accordance with the terms and conditions as set out therein. These documents, as amended from time to time, are available on the official website of the School at www.curro.co.za.

NB: The signatures of both parents and / or legal guardians are required where applicable.

____________________________________________________	____________________________
SIGNATURE OF FATHER / STEPFATHER / LEGAL GUARDIAN	DATE
____________________________________________________	____________________________
SIGNATURE OF MOTHER / STEPMOTHER / LEGAL GUARDIAN	DATE

PAGE 4 OF 7

SECTION 8 : DETAILS OF ACCOUNT HOLDER

SURNAME

FULL NAMES AS IN ID DOCUMENT

DESIGNATION

MR

MRS

MS

MISS

DR

REV

PROF

OTHER

IDENTITY NUMBER

RELATIONSHIP

MARITAL STATUS

OCCUPATION

EMPLOYER

RESIDENTIAL ADDRESS

WORK ADDRESS

POSTAL ADDRESS

CODE

CODE

CODE

TEL H CODE

TEL W

CODE

CELL

E-MAIL ADDRESS (PLEASE WRITE LEGIBLY)

PARENTAL STATUS

LEARNER LIVING WITH

LEARNER'S LEGAL

ACCESS RIGHTS TO

ACCESS RIGHTS IN AN

PARENT/S

GUARDIAN

LEARNER

EMERGENCY ONLY

DETAILS OF CHILDREN IN YOUR CARE WHO ARE CURRENTLY AT THIS SCHOOL

1

NAME

GR

2

NAME

GR

3

NAME

GR

4

NAME

GR

ANNUAL, AFTER TAX, COMBINED

LESS THAN

R 50 000 -

R100 000 -

R150 000 -

R200 000 -

R250 000 -

MORE THAN

HOUSEHOLD INCOME

R50 000 pa

R100 000 pa

R150 000 pa

R200 000 pa

R250 000 pa

R300 000 pa

R300 000 pa

PLEASE NOTE: This is for statistical purposes only and will NOT affect your child's acceptance status.

SECTION 9 : DECLARATION OF ACCOUNT HOLDER

We the undersigned, _________________________________________________________________, hereby certify that the information given by

the Account Holder in this Application for Admission is complete and accurate.

We accept joint and several liability to Campus and Property Management Company (Pty) Ltd and Meridian Operations Company NPC (RF) for the due and punctual payment of the annual, non-refundable registration fee, school fees, hostel fees and any other amounts which may become due and payable to the School or in respect of participation in or attendance of any extracurricular activity.

We accept the Financial Terms and Conditions of which a copy has been kept.

NB: The signatures of the account holder and that of the 2nd parent / a parent / legal guardian are required if applicable.

____________________________________________________	____________________________
SIGNATURE OF ACCOUNT HOLDER	DATE
____________________________________________________	____________________________
SIGNATURE OF 2ND PARENT / A PARENT / LEGAL GUARDIAN	DATE
____________________________________________________	____________________________
SIGNATURE OF AN AUTHORISED SCHOOL REPRESENTATIVE	DATE

PAGE 5 OF 7

SECTION 10 : FINANCIAL TERMS AND CONDITIONS

1.ACCEPTANCE OF LIABILITY

1.1The person responsible for the Account (hereafter the Account Holder) as set out in the standard Application for Admission (hereafter the Application) herewith assumes liability for the Account, alternatively binds him-/herself as co-debtor and surety for payment of all fees to the School.

1.2The legal guardian, as described in the Application, binds him-/herself as surety and co-debtor for the payment of all fees by the Account Holder or any other payments that may arise from this Agreement.

2.TERMS OF PAYMENT

2.1It is recorded that fees are determined at the beginning of the year and that the Account Holder is informed of the result in writing.

2.2The Account Holder shall immediately inform the School if he / she has not received an invoice at the start of the academic year.

2.3Fees for 11 (eleven) or 12 (twelve) months, depending on the specific School’s payment policy, are payable monthly in advance by means of debit order, electronic funds transfer or cash deposit at the bank on or before the 2nd (second) day of each calendar month or annually in advance by means of electronic funds transfer or cash deposit at the bank by 31 December, depending on the fee payment option exercised by the Account Holder in the Application for Admission.

2.4The School reserves the right to charge interest of 15% (fifteen percent) on all accounts that are in arrears by 30 (thirty) days or longer.

2.5Payment of monthly fees is not subject to presentation of a statement. Payments are made in accordance with the applicable fee structure of the School.

2.6In the event where an existing account is / has not been managed in the proper manner, no further Applications will be considered.

3.BREACH OF CONTRACT

In the event where the undersigned surety, Account Holder or legal guardian commits a breach of contract of any of the terms of this Agreement, the School may in its sole discretion:

3.1Refuse the learner entry to the School’s premises until the breach has been remedied; or

3.2Claim damages from the Account Holder and / or the surety and legal guardian; or

3.3Take whatever legal steps that may be necessary.

4.GENERAL

This Agreement constitutes the whole Agreement between the parties relating to the subject matter hereof. No amendment or consensual cancellation of this Agreement or any provision or term thereof or of any Agreement, bill of exchange or other document issued or executed pursuant to or in terms of the Agreement and no settlement of any disputes arising under this Agreement and no extension of time, waiver or relaxation or suspension of any of the provisions or terms of this Agreement or of any Agreement, bill or exchange or other document issued pursuant to or in terms of this Agreement shall be binding unless recorded in a written document signed by the parties. Any such extension, waiver or relaxation or suspension which is so given or made shall be strictly construed as relating strictly to the matter in respect whereof it was made or given.

5.JURISDICTION

This Agreement is subject to South African law.

6.CREDIT INFORMATION

The Account Holder, surety or legal guardian hereby consents to the disclosure and exchange of personal financial information to a credit bureau or financial institution in accordance with the National Credit Act.

7.DOMICILIUM

The parties choose as their domicilia citandi et executandi the addresses set out in the Application.

8.LEGAL FEES

In the event where the School takes legal action against the Account Holder, he / she will be liable for all legal fees on an attorney client scale, collection costs and commission, interest and tracing fees.

9.CANCELLATION

9.1The Account Holder undertakes to give 30 (thirty) calendar days written notice of termination of the enrolment of a learner, failing which the liability be incurred for the full amount of the following term’s fees.

9.2The School shall be entitled to terminate the enrolment of any learner under the following circumstances:

Summarily, and with immediate effect, if the learner is guilty of an offence which, in the sole opinion of the School, renders his / her continued enrolment at the School impossible, in which event the Account Holder, after deduction of all amounts otherwise owing to the School, will be refunded a pro-rata proportion of any fees already paid in advance in respect of such learner.

9.3In the event of emigration, which is a long process, the School requires 1 (one) full term’s written notice in advance.

____________________________________________________	____________________________
SIGNATURE OF ACCOUNT HOLDER	DATE

PAGE 6 OF 7

SECTION 11 : GENERAL INDEMNITY

1.The School and the Campus and Property Management Company (Pty) Ltd and Meridian Operations Company NPC (RF) Board of Directors undertake to implement reasonable and generally acceptable measures with regard to the safety and well-being of all learners, educators and visitors to the School.

2.Due to the nature of the matter, the School and the Campus and Property Management Company (Pty) Ltd and Meridian Operations Company NPC (RF) Board of Directors do not accept any responsibility for accidents that may take place in the class, on the school terrain or on the sports fields.

3.Each parent is therefore requested to complete this form as proof that you accept the position of the School and the Campus and Property Management Company (Pty) Ltd and Meridian Operations Company NPC (RF) Board of Directors as set out above as well as the risks involved therewith.

4.I, _________________________________________________, being the parent / legal guardian of

_______________________________________ who is enrolled as such and accepted by the School, subject to the terms set out herein, indemnify the School and the Campus and Property Management Company (Pty) Ltd and Meridian Operations Company NPC (RF) Board of Directors for the time being of the Campus and Property Management Company (Pty) Ltd (Reg Nr 2012/001821/07) and Meridian Operations Company NPC (RF) (Reg Nr 2012/081855/08) for any losses or damages in general, however they may occur, that I as parent / legal guardian of the above learner may suffer as a result of any occurrence whereby the learner may be involved, whether as the causing or suffering party, whilst participating in any school activity, except if such loss or damage arises as a consequence of the gross negligence or willful misconduct of the School or the Campus and Property Management Company Board of Directors or the Meridian Operations Company NPC (RF) Board of Directors or any person acting for or controlled by the School or the Campus and Property Management Company Board of Directors or the Meridian Operations Company NPC (RF) Board of Directors.

5.In particular, I authorise that the aforesaid learner may be involved in all excursions undertaken by his / her group or class during school days as part of his / her learning experience and, where applicable, I agree that he / she may utilise the transport arranged by the School for such excursions. I also indemnify the School and the Campus and Property Management Company (Pty) Ltd and Meridian Operations Company NPC (RF) Board of Directors for any damages or losses that I as parent / legal guardian of the above learner may suffer under such circumstances and voluntarily accepts the risks associated therewith, except if such loss or damage arises as a consequence of the gross negligence or willful misconduct of the School or the Campus and Property Management Company Board of Directors or the Meridian Operations Company NPC (RF) Board of Directors or any person acting for or controlled by the School or the Campus and Property Management Company Board of Directors or the Meridian Operations Company NPC (RF) Board of Directors.

6.In the event of the aforesaid learner making use of the bus service to and from the School, I acknowledge that I am aware that such service is operated by an independent contractor and that neither the School nor the Campus and Property Management Company (Pty) Ltd and Meridian Operations Company NPC (RF) Board of Directors accepts any responsibility therefore. The Campus and Property Management Company (Pty) Ltd and Meridian Operations Company NPC (RF) Board of Directors have, however, in awarding the right to operate the service, laid down certain conditions to ensure that the bus company complies with safety regulations and that the driver is sober and experienced with a proven and unblemished record.

SIGNED AT ______________________________________ ON THIS __________ DAY OF ___________________________ 20 _________.

AS WITNESSES:

1._____________________________________

2.____________________________________________________________________________

SIGNATURE OF PARENT / LEGAL GUARDIAN

SECTION 12 : PERMISSION TO USE PHOTOGRAPHS

I understand and acknowledge that, from time to time, informal photographs are taken of the School's learners, and that, insofar as these photographs are placed in the possession or control of the School and / or Curro Holdings Ltd and / or Campus and Property Management Company and / or Meridian Operations Company NPC (RF), these photographs might be used by the School and / or Curro Holdings Ltd and / or Campus and Property Management Company and / or Meridian Operations Company NPC (RF) in the electronic and / or printed media, including the Curro Holdings Ltd website, newspaper advertisements, magazine advertisements, brochures, flyers, posters, billboards, banners, flippers and signage on buildings and vehicles, which use will be solely for purposes of marketing the School and / or Curro Holdings Ltd and / or Campus and Property Management Company and / or Meridian Operations Company NPC (RF). As all marketing material of the School and / or Curro Holdings Ltd and / or Campus and Property Management Company and / or Meridian Operations Company NPC (RF) will, at all times, insofar as the use and publication of photographs are placed in the control of the School and / or Curro Holdings Ltd and / or Campus and Property Management Company and / or Meridian Operations Company NPC (RF), ensure that these photographs are used in good taste.

SIGNATURE OF PARENT / LEGAL GUARDIAN

SECTION 13 : SURVEY - SERVICES / FACILITIES REQUIRED

SECTION 14 : SURVEY - MARKETING

WHERE DID YOU HEAR ABOUT US? PLEASE INDICATE WITH AN X.

PLEASE INDICATE HOW SATISFIED YOU WERE WITH THE SERVICE RECEIVED PRE-ENROLMENT.