DIE-BOOMHUIS | Online Application

Please complete this form in full, fields marked with a * are required.

Proposed Start Date Term : *

Of Year : *

Proposed Start Date :

STUDENT DETAILS

Student's First Name *

Student's Last Name *

Student's Preferred Name (optional)

Student's Gender *

Male Female

Student's Date Of Birth *

Student's ID or Passport Number *

Home Language *

Allergies *

Allergy Action Required

Allergy Status *

Compulsory Immunisations Up to date *

Medical Aid Scheme

Medical Aid Number

Primary Members Details

Disclose whether your child suffers from any of the following conditions:

Emotional Issues Medical Conditions Psychological Problems Social Issues Previous Therapies or Recommendations Other

Home Medication

SIBLINGS

Select Number Of Siblings *

PREVIOUS SCHOOL DETAILS

School Name if applicable

Reason For Leaving

MOTHERS DETAILS

Relationship To Student *

Title *

First Name *

Last Name *

Email *

Home Phone Number

Mobile Phone Number *

Work Number

Address *

Nationality *

Parent Date of Birth

ID Number/Passport Number *

Marital Status *

Occupation

Position

Employer's Name

Employer's Number

FATHERS DETAILS

Relationship To Student

Title *

First Name *

Last Name *

Email *

Home Phone Number

Mobile Phone Number *

Work Number

Address*

Nationality *

Parent Date of Birth

ID Number/Passport Number *

Marital Status

Occupation

Position

Employer's Name

Employer's Number

OTHER CONTACTS

Doctor's Name *

Doctor's Phone Number *

Approved Pick Up Name

Approved Pick Up Phone Number

Their ID Number

Second Approved Pick Up Name

Second Approved Pick Up Phone Number

Their ID Number

Emergency Contact *

Emergency Contact Phone Number *

Second Emergency Contact

Second Emergency Contact Phone Number

Person Responsible For Account *

Enter Their Mobile Number *

Person Responsible Email Address*

DAILY OPTIONS

Half Day 7:30 - 17:30

Full Day 7:30 - 17:30

MEDIA CHANNEL PERMISSIONS

Do you consent to your child appearing in all School related media? *

LETTER MOTIVATING WHY THIS IS YOUR SCHOOL OF CHOICE

Maximum of 500 Characters

SUPPORTING DOCUMENTS

Student's Unabridged Birth Certificate *

Supported files : .jpg, .jpeg, .png

Proof of Payment
(Administration fee)

Supported files : .jpg, .jpeg, .png, pdf, doc, docx

Medical / Psychological / Therapist Reports

Supported files : .jpg, .jpeg, .png, pdf, doc, docx

Student Immunization Record

Supported files : .jpg, .jpeg, .png, pdf, doc, docx