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Admission Form
Student Information :
Surname:
First name:
Middle name:
Student Preferred Name:
Country:
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Gender:
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Male
Female
Residential address:
Date of birth:
Language spoken:
Other languages spoken:
Spoken English:
---------
Fluent
Developing
Writted English:
---------
Fluent
Developing
Student photo ext:
Parent / Guardian Information :
Father first name:
Father middle name:
Father surname:
Father mobile phone:
Father home phone:
Father email address:
Father work phone:
Father postal address:
Father ocupation:
Father employer info:
Father photo ext:
Mother surname:
Mother first name:
Mother middle name:
Mother mobile phone:
Mother home phone:
Mother email address:
Mother work line:
Mother postal address:
Mother ocupation:
Mother employer info:
Mother photo ext:
Siblings enrolled in school:
Siblings info:
Emergency Contact Information :
Emergency contact name:
Emergency contact email:
Emergency contact mobile phone:
Emergency contact home address:
Emergency contact work address:
Educational Background :
Class of entry:
Proposed entry date:
Name and address of previous school:
Name of teacher at previous school:
Special learning need:
Date of most recent educational plan:
Recent most educational plan examiner name:
Recent most educational plan examiner address:
Recent most educational plan examiner phone:
Date of recent language therapy:
Recent language therapy examiner name:
Recent language therapy examiner address:
Recent language therapy examiner phone:
Does student have current iep:
Is student receiving educational support:
Receiving es in current school:
Receiving individualized es:
Receiving es in small group:
Receiving private es:
Names of educational support providers:
Is student receiving language therapy:
Language theripy schedule:
Subject of language therapy:
Language therapist name:
Language therapist phone:
Is student receiving occupational therapy:
Occupational therapist name:
Occupational therapist phone:
Medical History :
Has medical condition:
---------
Yes
No
Describe medical condition:
Has medical restrictions:
---------
Yes
No
Describe medical restrictions:
Has allegies:
---------
Yes
No
Describe allegies:
Has medical history:
---------
Yes
No
Provide detail of medical history:
Family doctor name:
Family doctor contact detail:
Has medical cover:
---------
Yes
No
Provide medical cover detail:
Has security or child welfare cover:
---------
Yes
No
Provide detail of security or child welfare cover:
Student Service Requirement :
Does student require lunch:
---------
Yes
No
Is student vegetarian:
---------
Yes
No
Does student have dietary requirements:
---------
Yes
No
Describe dietary requirements:
Does student require therapy:
---------
Yes
No
Therapies:
Why choose Evergreen Inclusive_academy:
Payment/Sponsorship Information :
If payment by parent or guardian provide detail:
If payment by third party provide detail:
Third third party payment percentage limit:
Third party representative name:
Third party representative phone:
Third party representative email address:
Father has read and accepts condition:
---------
Yes
No
Mother has read and accepts condition:
---------
Yes
No
