APPLICATION FORM Please Note: You need to fill out THE INQUIRY form ON THE REGISTRATION PAGE before completing this form. PERSONAL DETAILS Childs 1st Name Childs Surname Childs Gender Childs Age Current Grade Grade Applying For Year Applying For PHYSICAL ADDRESS Street, complex etc Suburb City Province Country Postal Code EMPLOYMENT Employment Type Employer MOTHER OR GUARDIANS INFORMATION Full Name Surname ID Number Nationality Mobile No. Email PHYSICAL ADDRESS (If different from primary parent / guardians address) Street, complex etc Suburb City Province Country Postal Code CHILDS ACADEMIC INFORMATION Child's Last/Current School Schools Main Contact Number Schools Email Most Recent Grade Completed Date Started at Last/Current School Date Finished at Last/Current School Reason(s) For Leaving Last/Current School CHILDS ASSESSMENT INFORMATION AND LEARNING CHALLENGES Please indicate what assessments have been done. Leave blank if N/A Educational Psychologist Occupational Therapist Speech / Communication Therapist Audiologist Other What, in your opinion, are the child's main challenges pertaining to learning? MEDICAL INFORMATION. (Indicate "NONE" if N/A) Medical Aid Name. Medical Aid Scheme Medical Aid Number Main Member's Name Please list any medication that the child has been prescribed PERSON RESPONSIBLE FOR PAYMENT OF SCHOOL FEES Full Name(s) Surname ID No Nationality Mobile No. Email Physical Address (if different from primary/second parent/guardian's address) Street, Complex, etc Suburb City Province Country Postal Code Employer Employment Type Employer CREDIT CHECK Full Name Acceptance (Please check the acceptance box as confirmation) I hereby grant my informed consent to Capulum College in order to enable them to perform a confidential credit check on me for the purpose of compliance with the provisions of Section 81(2) of the National Credit Act, No. 34 of 2005 as amended, that relates to the prevention of the extension of reckless credit. I further understand that the credit report obtained under this content will be used by Capulum College solely for the purpose set out in Regulation 19(4) (c) to (g). Documents to be uploaded with this application: 1) Child's birth certificate 2) Most recent school report 3) Assessments from therapists/specialists in respect to the child's learning abilities 4) Parent(s) / Guardian(s) ID 5) Parent(s) / Guardian(s) proof of residence 6) 3 month's bank statements Upload Documents here.(Only PDF & JPG permitted) SUBMIT APPLICATION