Brookby School

ENROLMENT FORM

West Rd RD 1 Manurewa Ph: 09 5308569 [email protected]

STUDENT DETAILS Legal Surname:

Boy / Girl

Date of Birth:

Legal First Names: Preferred First Name:

Year Level: 0 1 2 3 4 5 6 7 8 Preferred Surname:

Address:

Siblings at Brookby School: Siblings Attending Brookby in the Future:

Ethnic Groups Child Relates To: 1. 2. 3. Phone:

Iwi: 1. 2. 3. Email:

Religious instruction: Yes / No

Custody Details: Do both parents have access to child? New Zealand Citizen: Yes / No Early Childhood Education: Yes / No Previous School:

Yes / No (Non-NZ residents Only) Date NZ Entry: Visa Expiry Date: Name of Centre: Year Level:

Passport copied by office Yes / No

PARENT/CAREGIVER DETAILS Name:

Name:

Address

Address:

Relationship to Child: Home Phone No: Work Phone No: Mobile Phone No: Email: Occupation:

Relationship to Child: Home Phone No: Work Phone No: Mobile Phone No: Email: Occupation:

EMERGENCY CONTACTS Name: Relationship to Child: Phone No: Mobile No:

Name: Relationship to Child: Phone No: Mobile No:

HEALTH Doctor: Ph: I consent to my child’s vision & hearing being tested: Yes / No Speech: Medication: Allergies: Learning / Behaviour Needs:

Immunisation Cert: Yes / No Hearing: Vision: Other: