LEARNERS PERSONAL DETAILS
Curro Holdings Ltd Reg No 1998/025801/06 / VAT Reg No 4670183484
SCHOOL APPLIED AT Cooper College
START DATE 2023-01-15
GROUP OR GRADE APPLIED FOR IGCSE Extended
CAMPUS Cooper College
HOSTEL ACCOMMODATION No
APPLICATION DATE 2022-12-27
HOSTEL APPLIED FOR 2022-12-27
YEAR APPLIED FOR
GRADE APPLIED FOR IGCSE Extended
AFTERCARE No
MONTH AND YEAR APPLIED FOR 2022-12-27
AFTERCARE OPTION
SCHOOL TRANSPORT No
MONTH AND YEAR APPLIED FOR 2022-12-27
BUS ROUTE APPLIED FOR
TIME OF DAY REQUIRED
NECESSARY SUPPORTING DOCUMENTS, COMPLETED SECTIONS AND FORMS
CEMIS transfer document once available
Copy of parents/legal guardians ID
Copy of learners FINAL progress report once available
Completed hostel application if applicable
Copy of learners latest progress report
Completed and signed debit-order form
Copy of learners birth certificate/ID
Subject choice form (FET phase: Gr 10 - Gr 12)
Copy of learners vaccination records if available
Sections 1 - 10 completed and signed
Copy of learners residence/study permit, if foreign
FOR OFFICE USE
INTERVIEW DATE APPROVED FAMILY CODE
NOTE DATE CREDIT REFERENCE
COMMENCEMENT DATE SIBLINGS AT 1
GROUP/GRADE THE SCHOOL 2
SECTION 1 : LEARNERS PERSONAL DETAILS
SURNAME Chinyere FULL NAMES Jesse
PREFERRED NAME Jesse IDENTITY NUMBER 060301 5218 085
DATE OF BIRTH 2006-03-01 AGE 17 GENDER MALE
HOME AND OTHER SPOKEN LANGUAGE/S HOME ENGLISH OTHER
LANGUAGE/S OF LEARNING AND TEACHING FIRST ENGLISH SECOND ENGLISH
NATIONALITY South Africa COUNTRY OF ORIGIN Nigeria
DATE OF IMMIGRATION 2006-03-01 RACE AFRICAN
RELIGION christian RESIDENCE Parents
TRANSPORT TO/FROM LEARNERS CELLPHONE
SCHOOL NUMBER
NUMBER OF CHILDREN
0 POSITION OF CHILD IN FAMILY 0
IN FAMILY
SECTION 2 : LEARNERS EDUCATION DETAILS
CURRENT SCHOOL NAME Acacia TEL NO 27 11 704 1113
ADDRESS CODE
PRINCIPLE
PREVIOUS SCHOOL NAME TEL NO
ADDRESS CODE
PRINCIPLE
LAST GRADE PASSED 10 YEAR 2022 GRADE/S REPEATED
HAS ADMISSION TO ANY OTHER SCHOOL/S EVER BEEN REFUSED? IF YES, PLEASE
YES NO X
STATE REASON.
REASON
ACADEMIC ACHIEVEMENTS EXTRAMURAL ACHIEVEMENTS OTHER ACHIEVEMENTS
SECTION 3 : LEARNERS MEDICAL DETAILS
BLOOD TYPE A+
FAMILY DOCTOR NAME TEL NO
ADDRESS
MEMBER
MEDICAL AID NAME NONE
NUMBER
MAIN MEMBER
INITIALS AND
SURNAME
MAIN MEMBER
ID NUMBER
OPTION
HAS THE LEARNER RECEIVED ALL THE NECESSARY IMMUNISATIONS? IF NO, PLEASE
YES X NO
STATE REASON.
REASON
HAS THE LEARNER SUFFERED FROM ANY OF THE FOLLOWING ILLNESSES? PLEASE INDICATE WITH AN X.
Asthma Chickenpox Diabetes Diphtheria
Enteric fever German measles Hepatitis Malaria
Measles Mumps Poliomyelitis Rheumatic fever
Scarlet fever Tickbite fever Typhoid fever Whooping cough
DOES THE LEARNER SUFFER FROM ANY ALLERGIES? YES NO X
IF YES, PLEASE GIVE DETAILS
DOES THE LEARNER HAVE ANY SPECIAL MEDICAL NEEDS? YES NO X
IF YES, PLEASE GIVE DETAILS
DOES OR HAS THE LEARNER SUFFERED FROM ANY OTHER ILLNESSES OR
YES NO X
DISABILITIES?
IF YES, PLEASE GIVE DETAILS
IS THE LEARNER RECEIVING MEDICAL TREATMENT FOR ANY CONDITION? YES NO X
IF YES, PLEASE GIVE DETAILS
IS OR HAS THE LEARNER SUFFERED FROM OR RECEIVED TREATMENT FOR ANY
YES NO X
PSYCHOLOGICALYESNOXOR EMOTIONAL UPSET?
IF YES, PLEASE GIVE DETAILS
HAS THE LEARNER HAD ANY OPERATIONS? YES NO X
IF YES, PLEASE GIVE DETAILS
PLEASE SPECIFY ANY OTHER RELEVANT MEDICAL DETAILS
SECTION 3 : LEARNERS MEDICAL DETAILS - CONSENT
IN A CRITICAL MEDICAL SITUATION, PLEASE BEAR IN MIND THAT THERE MAY NOT BE TIME TO REFER TO THE
LEARNERS RECORDS. THE SCHOOLTHEREFORE RESERVES THE RIGHT TO UTILISE THE QUICKEST MEDICAL
SERVICE AVAILABLE.
I
BEING THE PARENT/LEGAL GUARDIAN/S OF
/WE,
HEREBY AGREE THAT A MEDICAL PRACTITIONER MAY PROVIDE EMERGENCY TREATMENT AS MAY BE
NECESSARY.
SIGNATURE OF PARENT/LEGAL GUARDIAN
/S
SECTION 4 : DETAILS OF LEGAL GUARDIAN
SURNAME Chinyere FULL NAMES Sandra
IDENTITY
DESIGNATION Mrs A02704312
NUMBER
RELATIONSHIP Mother MARITAL STATUS MARRIED
OCCUPATION Freelancer EMPLOYER Self employed
WORK
HOME TELEPHONE
TELEPHONE
PARENTAL
CELL NUMBER 27 083 988 5561 Living with Parent
STATUS
EMAIL ADDRESS chinyerejesse@[Link]
RESIDENTIAL
69A blandford road 69, La muette , North riding , Joburg , Gauteng , Gauteng
ADDRESS
WORK ADDRESS ,,,,,
POSTAL ADDRESS 69A blandford road 69, La muette , North riding , Joburg , Gauteng , Gauteng
SECTION 5 : DETAILS OF LEGAL GUARDIAN
SURNAME FULL NAMES
IDENTITY
DESIGNATION
NUMBER
RELATIONSHIP MARITAL STATUS
OCCUPATION EMPLOYER
WORK
HOME TELEPHONE
TELEPHONE
PARENTAL
CELL NUMBER
STATUS
EMAIL ADDRESS
RESIDENTIAL
,,,,,
ADDRESS
WORK ADDRESS ,,,,,
POSTAL ADDRESS ,,,,,
SECTION 6 : DETAILS OF ANOTHER CONTACT IN THE CASE OF AN EMERGENCY
SURNAME Chinyere FULL NAMES Sandra
HOME
RELATIONSHIP Mother 27 083 988 5561
TELEPHONE
WORK TELEPHONE 27 083 988 5561 CELL NUMBER 27 083 988 5561
EMAIL ADDRESS
SECTION 7 : DETAILS OF ACCOUNT HOLDER
SURNAME Chinyere FULL NAMES Sandra
IDENTITY
DESIGNATION Mrs A02704312
NUMBER
RELATIONSHIP Mother MARITAL STATUS MARRIED
OCCUPATION Freelancer EMPLOYER Self employed
WORK
HOME TELEPHONE
TELEPHONE
PARENTAL
CELL NUMBER 27 083 988 5561 Living with Parent
STATUS
EMAIL ADDRESS chinyerejesse@[Link]
RESIDENTIAL
69A blandford road 69, La muette , North riding , Joburg , Gauteng , Gauteng
ADDRESS
WORK ADDRESS ,,,,,
POSTAL ADDRESS 69A blandford road 69, La muette , North riding , Joburg , Gauteng , Gauteng
DETAILS OF CHILDREN IN SCHOOL
1 NAME GR
2 NAME GR
3 NAME GR
4 NAME GR
PAYMENT OPTION
SECTION 8 : SIGNATURE OF PARENTS/LEGAL GUARDIAN AND/OR ACCOUNT HOLDER
I/We, the undersigned, , hereby certify that the information provided
in this application for admission is complete and accurate. I/We acknowledge that enrolment is subject to, inter alia, signing a
learner admission contains the detailed terms, conditions and reIuirements for admission.
I/We hereby authorise the school and/or any of its associates to conduct any credit enIuiries on us as may be necessary from time to
time.
I/We ackowledge that we have read the school-specific policies and school rules and will accept an offer of placement for our child
at the school in the terms and conditions as set out therein. These documents, as amended from time to time, are available on the
official school website.
NB: The signatures of the account holder and both parents and/or legal guardians are required where applicable.
SIGNATURE OF ACCOUNT HOLDER DATE
SIGNATURE OF FATHER/STEPFATHER/LEGAL
DATE
GUARDIAN
SIGNATURE OF MOTHER/STEPMOTHER/LEGAL
DATE
GUARDIAN
SECTION 9 : SURVEY - SERVICES/FACILITIES REQUIRED
SCHOOL TRANSPORT No FROM WHERE?
HOLIDAY CARE No
MUSIC TUITION No INSTRUMENT(S)
SECTION 10 : SURVEY - MARKETING
WHERE DID YOU HEAR ABOUT US? Friend
HOW SATISFIED WERE YOU WITH THE SERVICE RECEIVED PRE-
Satisfied
ENROLMENT?
THE INFORMATION RECEIVED PRE-ENROLMENT WAS? Informative
SECTION 11 : WHY CURRO
SELECT WHY CURRO IS YOUR SCHOOL OF CHOICE? Performing arts and culture offering
Academic standards
Sport offering
Teachers
Ethos