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HERITAGE HOUSE MONTESSORI SCHOOL
Entry	
  form	
  into	
  Heritage	
  House	
  Montessori	
  School	
  
	
  (To	
  be	
  completed	
  and	
  returned	
  to	
  the	
  Head	
  of	
  School)	
  
	
  
	
  	
  Session:	
  20	
  ________________	
  /	
  20	
  ____________________	
  
	
  
Date	
  of	
  Application:___________________________	
  	
  Class	
  Applying	
  for:	
  ________________	
  
	
  
THIS	
  FORM	
  DOES	
  NOT	
  GUARANTEE	
  ADMISSION	
  
	
  
Applicants	
  for	
  places	
  in	
  Heritage	
  House	
  School,	
  who	
  are	
  NOT	
  either	
  the	
  Father	
  of	
  the	
  child	
  (or	
  children)	
  they	
  
are	
  enrolling	
  MUST	
  delete	
  the	
  word	
  PARENT	
  and	
  insert	
  their	
  own	
  status	
  in	
  regard	
  to	
  that	
  child	
  (or	
  children)	
  
e.g	
  UNCLE,	
  COUSIN	
  
This	
  form	
  must	
  be	
  accompanied	
  by:	
  
• Four	
  recent	
  	
  passport	
  photographs	
  of	
  the	
  child	
  
• Original	
  (for	
  sighting	
  only	
  and	
  photocopy	
  of	
  the	
  child’s	
  birth	
  certificate	
  
• Last	
  result	
  of	
  	
  former	
  school	
  (where	
  applicable)	
  
• Original	
  (for	
  sighting	
  only	
  and	
  photocopy	
  of	
  the	
  child’s	
  Immunization	
  records)	
  
	
  
APPLICANT’S	
  INFORMATION	
  
Child’s	
  Name:	
  __________________________________________________________________________________________	
  
	
   	
   	
   	
   	
   	
   SURNAME	
  
	
  
Other’s	
  Names:	
  _______________________________________________________________________________________________________	
  
	
   	
   	
   	
   	
   FIRST	
   	
   	
   	
   	
   	
   MIDDLE	
  
	
  
Date	
  of	
  Birth:	
  _________________________	
  Sex:	
  __________________	
  	
  	
  First	
  Language	
  of	
  Child:	
  __________________________	
  
	
   	
   	
  	
  	
  	
  	
  dd/mm/yy	
  
	
  
Nationality:	
  _________________________________________	
  	
  	
  	
  State	
  of	
  Origin:	
  ________________________________________________	
  
	
  
	
  Year/Term	
  desire	
  to	
  start:	
  _____________________________________________________________________________________________	
  
	
  
	
  
	
  
	
  
	
  
	
  
Insert	
  	
  recent	
  photo	
  
here	
  
 
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
Name	
  of	
  last	
  school	
  (s)	
  attended	
  with	
  dates:	
  ________________________________________________________________________	
  
________________________________________________________________________________________________________________________________	
  
School	
  Address:	
  ________________________________________________________________________________________________________	
  
	
  
___________________________________________________________________________________________________________________________	
  
	
  
School	
  Telephone:	
  ___________________________________	
  	
  Principal/Head	
  Teacher:	
  ______________________________	
  
	
  
Has	
  the	
  applicant	
  ever	
  been	
  referred	
  to	
  anyone	
  for	
  academic	
  evaluation,	
  testing,	
  tutoring,	
  etc?	
  	
  	
  
	
  
Yes	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  No	
  
	
  
If	
  yes,	
  give	
  date	
  and	
  reason.	
   	
   	
   Date:	
  ___________________________	
  
	
  
Reason:	
  _________________________________________________________________________________________________________________	
  
	
  
___________________________________________________________________________________________________________________________	
  
	
  
___________________________________________________________________________________________________________________________	
  
	
  
PARENTS	
  /	
  GUARDIAN	
  INFORMATION	
  
	
  
Father’s	
  Name:________________________________________________________________________________________________________	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  SURNAME	
   	
   	
   	
   	
   	
   OTHER	
  NAMES	
  
	
  
Nationality:	
  ______________________________________________	
  	
  	
  	
  	
  	
  Occupation:__________________________________________	
  	
  
	
  
How	
  would	
  like	
  to	
  be	
  addressed	
  ?	
  Mr	
  &	
  Mrs/Mrs/	
  Mr/	
  Dr./	
  Chief/	
  Pastor/	
  Others:	
  
	
  
Residential	
  Address:	
  _________________________________________________________________________________________________	
  
	
  
Office	
  Name	
  &	
  	
  Address:_____________________________________________________________________________________________	
  
	
  
___________________________________________________________________________________________________________________________	
  
	
  
Phone	
  Number	
  Office	
  (Landline):	
  _____________________________________	
  GSM:	
  _____________________________________	
  
	
  
E-­mail	
  Address:	
  _______________________________________________________________________________________________________	
  
	
  
Home	
  (Landline):________________________________________________________	
  GSM:	
  _______________________________________	
  
	
  
Mother’s	
  Name:	
  _______________________________________________________________________________________________________	
  
	
   	
   	
   	
   SURNAME	
   	
   	
   	
   	
   OTHER	
  NAMES	
  
	
  
Nationality:	
  _____________________________________________________________	
  Occupation:________________________________	
  
	
  
Residential	
  Address:	
  __________________________________________________________________________________________________	
  
	
  
___________________________________________________________________________________________________________________________	
  
	
  
___________________________________________________________________________________________________________________________	
  
 
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
Office	
  Name	
  &	
  Address:________________________________________________________________________________	
  
____________________________________________________________________________________________________	
  
E-­‐mail	
  Address:	
  _______________________________________________________________________________________	
  
Phone	
  No	
  Office	
  (Landline):	
  _____________________________________	
  GSM	
  :	
  _________________________________	
  
Home	
  (Landline):	
  ______________________________________________	
  GSM:	
  _________________________________	
  
Child	
  live	
  with	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Both	
  parents	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Father	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Mother	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Other	
  	
  ________________	
  
Tick	
  	
  any	
  that	
  apply:	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Father	
  is	
  deceased	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Parents	
  are	
  divorced	
  
	
   	
   	
   	
  	
  	
  	
  	
  	
  	
  	
  Mother	
  is	
  deceased	
   	
   Parents	
  are	
  separated	
  
Name	
  and	
  Address	
  (Where	
  applicable)	
  of:	
  
Guardian:	
  __________________________________________________________________________________________	
  
Occupation:_________________________________________________________________________________________	
  	
  
Phone	
  No	
  (Office	
  Landline):	
  _____________________________________GSM	
  :	
  __________________________________	
  
Home	
  (Landline):	
  ______________________________________________	
  GSM:	
  __________________________________	
  
Parents/Guardian:	
  Please	
  explain	
  why	
  you	
  wish	
  to	
  enroll	
  this	
  child	
  in	
  Heritage	
  House	
  Montessori	
  School	
  
___________________________________________________________________________________________________	
  
___________________________________________________________________________________________________	
  
__________________________________________________________________________________________________	
  
___________________________________________________________________________________________________	
  
	
  
ADDITIONAL	
  FAMILY	
  INFORMATION	
  
	
  
Number	
  of	
  Siblings:_________________	
  Age	
  of	
  Siblings	
  (Brother(S):__________________	
  Sister(s):_________________	
  
Position	
  of	
  child	
  in	
  the	
  family:__________________________________________________________________________	
  
	
  
	
  
	
  
	
  
	
  
	
  
 
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
   	
  
	
   	
  	
  	
  	
  	
  	
  	
  	
  
MEDICAL	
  INFORMATION	
  
Family	
  Doctor:	
  __________________________________________Doctor	
  Tel	
  No:	
  ___________________________	
  
Doctor’s	
  Address:	
  ____________________________________________________________________________________	
  
Any	
  dietary	
  Restriction/Allergies:	
  ________________________________________________________________	
  
Immunization	
  details:	
  Measles/Mumps/Rubella	
  (MMR)	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Polio	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Tetanus	
  
	
   	
   	
   	
   	
   	
  
Diphtheria	
  Whooping	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Cough	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  BCG	
  
	
  
Does	
  your	
  child	
  suffer	
  from	
  any	
  of	
  these?	
  	
  Epilepsy	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Seizures	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Asthma	
  
	
  
Any	
  other	
  information;	
  _____________________________________________________________________________	
  
I	
  give	
  permission	
  for	
  my	
  child	
  to	
  be	
  given	
  medication	
  by	
  the	
  staff	
  as	
  instructed	
  at	
  times	
  	
  
of	
  illness;	
  	
  	
  Yes	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  No	
  
I	
  give	
  permission	
  for	
  my	
  child	
  to	
  be	
  taken	
  to	
  hospital	
  in	
  case	
  of	
  emergency	
  
Yes	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  No	
  
	
  
I/We	
  jointly	
  and	
  severally	
  agree	
  to	
  abide	
  by	
  the	
  conditions	
  and	
  rules	
  in	
  the	
  conditions	
  
of	
  admission	
  overleaf	
  and	
  in	
  the	
  prospectus	
  and	
  policies	
  of	
  the	
  school.	
  	
  I/We	
  accept	
  
that	
  under	
  this	
  agreement,	
  we	
  are	
  liable	
  for	
  all	
  school	
  fees	
  and	
  extra,	
  including	
  
interest	
  incurred.	
  
Signature:	
   	
   Mother	
   	
   	
   	
   	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Father:	
  
	
  
Date:	
  	
   	
   	
   	
   	
   	
  	
  	
  	
  	
  	
  	
  	
  	
  Date:	
  
	
  
Name	
  of	
  Organization	
  or	
  person	
  responsible	
  for	
  paying	
  school	
  fees:	
  
	
  
__________________________________________________________________________________________________________	
  
NB:	
  This	
  form	
  must	
  be	
  signed	
  by	
  BOTH	
  parents	
  or	
  legal	
  Guardians	
  of	
  the	
  child.	
  
	
  

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Heritage house-montessori-admission-form

  • 1.                                                                                                                                                                                                               HERITAGE HOUSE MONTESSORI SCHOOL Entry  form  into  Heritage  House  Montessori  School    (To  be  completed  and  returned  to  the  Head  of  School)        Session:  20  ________________  /  20  ____________________     Date  of  Application:___________________________    Class  Applying  for:  ________________     THIS  FORM  DOES  NOT  GUARANTEE  ADMISSION     Applicants  for  places  in  Heritage  House  School,  who  are  NOT  either  the  Father  of  the  child  (or  children)  they   are  enrolling  MUST  delete  the  word  PARENT  and  insert  their  own  status  in  regard  to  that  child  (or  children)   e.g  UNCLE,  COUSIN   This  form  must  be  accompanied  by:   • Four  recent    passport  photographs  of  the  child   • Original  (for  sighting  only  and  photocopy  of  the  child’s  birth  certificate   • Last  result  of    former  school  (where  applicable)   • Original  (for  sighting  only  and  photocopy  of  the  child’s  Immunization  records)     APPLICANT’S  INFORMATION   Child’s  Name:  __________________________________________________________________________________________               SURNAME     Other’s  Names:  _______________________________________________________________________________________________________             FIRST             MIDDLE     Date  of  Birth:  _________________________  Sex:  __________________      First  Language  of  Child:  __________________________                dd/mm/yy     Nationality:  _________________________________________        State  of  Origin:  ________________________________________________      Year/Term  desire  to  start:  _____________________________________________________________________________________________               Insert    recent  photo   here  
  • 2.                                                             Name  of  last  school  (s)  attended  with  dates:  ________________________________________________________________________   ________________________________________________________________________________________________________________________________   School  Address:  ________________________________________________________________________________________________________     ___________________________________________________________________________________________________________________________     School  Telephone:  ___________________________________    Principal/Head  Teacher:  ______________________________     Has  the  applicant  ever  been  referred  to  anyone  for  academic  evaluation,  testing,  tutoring,  etc?         Yes                        No     If  yes,  give  date  and  reason.       Date:  ___________________________     Reason:  _________________________________________________________________________________________________________________     ___________________________________________________________________________________________________________________________     ___________________________________________________________________________________________________________________________     PARENTS  /  GUARDIAN  INFORMATION     Father’s  Name:________________________________________________________________________________________________________                                                                                                    SURNAME             OTHER  NAMES     Nationality:  ______________________________________________            Occupation:__________________________________________       How  would  like  to  be  addressed  ?  Mr  &  Mrs/Mrs/  Mr/  Dr./  Chief/  Pastor/  Others:     Residential  Address:  _________________________________________________________________________________________________     Office  Name  &    Address:_____________________________________________________________________________________________     ___________________________________________________________________________________________________________________________     Phone  Number  Office  (Landline):  _____________________________________  GSM:  _____________________________________     E-­mail  Address:  _______________________________________________________________________________________________________     Home  (Landline):________________________________________________________  GSM:  _______________________________________     Mother’s  Name:  _______________________________________________________________________________________________________           SURNAME           OTHER  NAMES     Nationality:  _____________________________________________________________  Occupation:________________________________     Residential  Address:  __________________________________________________________________________________________________     ___________________________________________________________________________________________________________________________     ___________________________________________________________________________________________________________________________  
  • 3.                                                                                         Office  Name  &  Address:________________________________________________________________________________   ____________________________________________________________________________________________________   E-­‐mail  Address:  _______________________________________________________________________________________   Phone  No  Office  (Landline):  _____________________________________  GSM  :  _________________________________   Home  (Landline):  ______________________________________________  GSM:  _________________________________   Child  live  with                                      Both  parents                                                  Father                                          Mother                                                          Other    ________________   Tick    any  that  apply:                              Father  is  deceased                                                            Parents  are  divorced                        Mother  is  deceased     Parents  are  separated   Name  and  Address  (Where  applicable)  of:   Guardian:  __________________________________________________________________________________________   Occupation:_________________________________________________________________________________________     Phone  No  (Office  Landline):  _____________________________________GSM  :  __________________________________   Home  (Landline):  ______________________________________________  GSM:  __________________________________   Parents/Guardian:  Please  explain  why  you  wish  to  enroll  this  child  in  Heritage  House  Montessori  School   ___________________________________________________________________________________________________   ___________________________________________________________________________________________________   __________________________________________________________________________________________________   ___________________________________________________________________________________________________     ADDITIONAL  FAMILY  INFORMATION     Number  of  Siblings:_________________  Age  of  Siblings  (Brother(S):__________________  Sister(s):_________________   Position  of  child  in  the  family:__________________________________________________________________________              
  • 4.                                               MEDICAL  INFORMATION   Family  Doctor:  __________________________________________Doctor  Tel  No:  ___________________________   Doctor’s  Address:  ____________________________________________________________________________________   Any  dietary  Restriction/Allergies:  ________________________________________________________________   Immunization  details:  Measles/Mumps/Rubella  (MMR)                        Polio                            Tetanus               Diphtheria  Whooping                                      Cough                                    BCG     Does  your  child  suffer  from  any  of  these?    Epilepsy                          Seizures                          Asthma     Any  other  information;  _____________________________________________________________________________   I  give  permission  for  my  child  to  be  given  medication  by  the  staff  as  instructed  at  times     of  illness;      Yes                              No   I  give  permission  for  my  child  to  be  taken  to  hospital  in  case  of  emergency   Yes                                        No     I/We  jointly  and  severally  agree  to  abide  by  the  conditions  and  rules  in  the  conditions   of  admission  overleaf  and  in  the  prospectus  and  policies  of  the  school.    I/We  accept   that  under  this  agreement,  we  are  liable  for  all  school  fees  and  extra,  including   interest  incurred.   Signature:     Mother                                                Father:     Date:                              Date:     Name  of  Organization  or  person  responsible  for  paying  school  fees:     __________________________________________________________________________________________________________   NB:  This  form  must  be  signed  by  BOTH  parents  or  legal  Guardians  of  the  child.