Child’s first name: *

Child’s surname: *

D.O.B: *

Age: *

Preferred name:

Gender: *

Male

Female

Home Address: *

21558 PEACH STR
Protea Glen Ext29

Post code: *

Birth certificate no:

Primary contact first name: *

Surname: *

Relationship: *

Address: *

21558 PEACH STRProtea Glen Ext29

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?: *

Yes

Details:

none

Secondary contact first name: *

Surname: *

Relationship: *

Address: *

21558 PEACH STR; Protea Glen Ext29

Contact number: *

Work number:

Email address:

Occupation:

Custody of the child is with: *

Primary contact

Secondary contact

Both (joint custody)

Other

Contact no.1 name: *

Relationship: *

Address: *

36566 Amber Ave
Protea Glen Ext40

Mobile number: *

Work number:

Contact No.2 name:

Relationship:

Address:

28613 sand street protea glen

Mobile number:

Work number:

I, hereby consent and grant permission to the following persons to collect my child (Must be 18 years or over): *

Pat Mogano

Doctor's name:

Surgery address:

protea glen bp garage on the right

Surgery phone Number:

Allergens severity: *

Very high

High

Medium

Low

Allergen's Name:

Medical condition(s) if any:

Does your child have any dietary requirements?:

Yes

Special needs:

Specific likes/dislikes:

None

Medication (Please list any medication your child takes regularly and the dosage):

n/a

Does your child have any special educational needs (SEN)?:

Yes

If your child has any learning difficulties/disabilities or requires additional assistance, please list them here:

None

Any other relevant information we may need to be aware of ?:

n/a

Religion:

Christian

Muslim

Buddhist

Jewish

Sikh

Hindu

None

Prefer not to say

Others - please state

Secret password: *

Other Religion:

Home language: *

Sepedi

Any other relevant information:

n/a

Please read our Terms & Conditions View T&C's

Any other instructions : Please send a copy of your child’s birth certificate, immunization records via Cheqdin’s registration messages section in your web portal login or email it to thelearningtree.protea@gmail.com. Please check - Terms & Conditions:

Declaration :

I accept the terms and conditions of The Learning Tree Nursery and Preschool

Yes No

Full Name of Parent/Carer:

Digital Signature

Pat Mogano

Date & time:

04, Jan 2021 02:28 pm

The Learning Tree Nursery and Preschool

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service