19 Lyndhurst Rd Kimberley Tel 053 832 7939

Application and childs personal information

Child

Surname

Full names

Name known by

Date of birth (yy/mm/dd) Age:

Home address

Home Tel no:

Home language

Religion

Position of child in family First Second Third

Left/Right handed Left: Right:

Father/Guardian

Surname

First name

ID Number

Occupation

Place of work

Work Tel Number

Cell Number

E-mail address

Marital status Married Divorced Single Widowed

Religion
Mother/Guardian
Surname

First name

ID Number

Occupation

Place of work

Work Tel Number

Cell Number

E-mail address

Marital status Married Divorced Single Widowed

Religion

General information

Family Doctor

Doctors Tel No.

Allergies/Medication

Please note: If a child needs medication when he/she is sick, the medicine
register will have to be signed by the parent/guardian to give the teacher
permission to administer the medicine.

Other information
about child

Main contact person

Alternative contact Name of contact:

numbers
Contact numbers:

relation to child (e.g. granny):

My child will be Parent:

fetched by
Transport Relative Friend Tel no:

Name: Cell no:

 After care

Previous school

Any therapy Speech Behavioural Occupational

attended (past or
present)

Siblings attending
LPPC

Any additional
information you
would like us to
know

Please tick each box:

I AGREE TO ABIDE BY THE RULES OF THE SCHOOL AND AM WILLING TO PAY THE ABOVE FEES IN
ADVANCE BY THE 7th OF THE MONTH.

I AGREE TO GIVE ONE MONTHS WRITTEN NOTICE SHOULD I DECIDE TO WITHDRAW MY CHILD AND
I AGREE TO SUBMIT ONE MONTHS FEE REGARDLESS OF WHETHER THE CHILD IS AT SCHOOL IN THE
NOTICE MONTH OR NOT.

I WILL INFORM THE SCHOOL OF ANY CHANGE IN PHONE NUMBERS OR ADDRESSES.

I, AS THE PERSON WHO SIGNS THIS FORM IS RESPONSIBLE FOR ALL SCHOOL AND/OR AFTERCARE
FEES.

I PERMIT MY CHILDS PHOTOGRAPH TO BE PUT ON THE LPPC WEBSITE AND FACEBOOK PAGE.

SIGNED: ________________________________ DATE: __________________________________

I, the undersigned, ____________________ in my capacity as Guardian/duly authorized by the Guardian of

__________________________________ hereby expressly renounce any claim which may arise from the
death or bodily injury to the said child and acknowledge that neither the Kimberley Baptist Church, the Little
Peoples Play Centre, any member of staff or the driver of any vehicle whilst on an official school outing or
transporting to or from Aftercare, consented by the parent or guardian of such child, shall be liable for
damages sustained from any occurrence, whether such claim has arisen from negligence of any of the
aforesaid persons or otherwise. This renunciation does not, however, exclude any claim which may be
instituted against any third party insurer in terms of the Motor Vehicle Assurance Act, No 56 of 1972, as
amended.

SIGNED: _____________________________________________ DATE: _______________