This infant admission form collects personal information about a child such as name, date of birth, address, and health information. It also requests contact information for parents/guardians and emergency contacts. The form notes that a photocopy of the birth certificate must be included and informs parents that submitting the form does not guarantee admission, and falsified forms will be considered void. It provides details on where and when completed forms should be returned.

1. Infant Admission Form
This form should be completed in BLOCK CAPITALS.
Please read the instruction sheet carefully before completing the form.
SECTION I (PERSONAL INFORMATION)
1. Name of Child ………………………………………………………………………………...
(First) (Middle) (Last)
2. Date of Birth ………………………………... 3. Citizenship …………………………
4. Religion ………………………………..
5. Address at which child resides:…………………………………………………………………
6. Telephone Number (s): ……………………………………………………………………
7. E-mail Address: …………………………………………………..
8. Pre-school child attended: …………………………………………………………………
9. Address of Pre-School: ……………………………………………………………………
10. Phone Number of Pre-School: ……………………………………
(A photocopy of the computerized birth certificate must accompany this form.)
Laventille Boys Government Primary School
Tousaint Trace, Old St. Joseph Rd., Laventille
Phone/Fax: 623-3996
E-mail: laventilleboys@gmail.com
Principal: Mr. Carel Lewis
Senior Teacher: Ms. Lyra Bonaparte

2. SECTION II (HEALTH INFORMATION)
12. Has the child been inoculated? Please tick ( ) one response. Yes ( ) No ( )
(If yes, then write all the information required below from the immunization card.)
Dates Dates
Diph/Tet. …………………… Polio ……………………
…………………… ……………………
…………………… ..………………….
…………………… ……………………
…………………… ……………………
Yellow Fever …………………… Measles/ Rubella …………………….
13. Has the child received treatment for any of the following? Please tick ( ) all that apply.
Asthma ( ) Scabies ( ) Nose Bleed ( )
Bronchitis ( ) Small Pox ( ) Heart Disease ( )
Fits ( ) Skin Disorder ( ) Rheumatic Fever ( )
14. Any others not listed above: ………………………………………………………………
15. Allergies (please state): ……………………………………………………………………

3. SECTION III (FAMILY INFORMATION)
16. Mother’s Name : ……………………………………………………………………………
Postal Address : ……………………………………………………………………………
…………………………………………………………………………….
Occupation : ………………………………………………………………………………..
Employer’s Address : ………………………………………………………………………
………………………………………………………………………
17. Father’s Name : …………………………………………………………………………….
Postal Address : …………………………………………………………………………….
…………………………………………………………………………….
Occupation : ………………………………………………………………………………..
Employer’s Address : ………………………………………………………………………
………………………………………………………………………
18. Guardian’s Name : …………………………………………………………………………
Postal Address : …………………………………………………………………………….
…………………………………………………………………………...
Occupation : ………………………………………………………………………………..
Employer’s Address : ………………………………………………………………………
………………………………………………………………………
19. In case of an emergency, please contact:
Name Phone Number
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

4. 20. Name(s) of brother(s) attending the school:
Name Class
…………………………………………………………………………………………….
…………………………………………………………………………………………….
……………………………………………………………………………………………..
………………………………. …………………………………...
Date Signature of Parent / Guardian
PLEASE NOTE
 Completed application forms are to be returned to the Principal by Monday 9th March, 2015.
No application forms will be considered after this date.
 Application forms will not be accepted without the requested documents and signature affixed thereto.
The completion of this form is not a guarantee that the child would be admitted.
 Application forms with falsified information will be considered null and void.
 The completed application along with a passport size photograph must be returned by the Parent/Guardian of the
child who is to be considered for admission. The form must NOT be sent with a child.