Outeniqua-Academy | Online Application

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

Proposed Start Date Term : *

Of Year : *

Grade/Class Applying For *

Proposed Start Date :

STUDENT DETAILS

Student's First Name *

Student's Last Name *

Student's Preferred Name (optional)

Student's Mobile Number

Student's Email Address(optional)

Student's Gender *

Male Female

Student's Date Of Birth *

Student's ID or Passport Number *

Nationality *

Place of Birth*

Home Language *

Allergies *

Allergy Action Required

Allergy Status *

Compulsory Immunisations Up to date *

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

Emotional Issues Medical Conditions Psychological Problems Social Issues Other

SIBLINGS

Select Number Of Siblings *

PARENT / GUARDIAN 1 DETAILS

Relationship To Student *

Title *

First Name *

Last Name *

Email *

Home Phone Number

Mobile Phone Number *

Work Number

Address *

ID Number/Passport Number *

Marital Status *

Occupation

Position

PARENT / GUARDIAN 2 DETAILS

Relationship To Student

Title *

First Name *

Last Name *

Email *

Home Phone Number

Mobile Phone Number *

Work Number

Address*

ID Number/Passport Number *

Marital Status

Occupation

Position

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*

MEDIA CHANNEL PERMISSIONS

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

Upload a recent headshot of your child

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SUPPORTING DOCUMENTS

Student's Unabridged Birth Certificate

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Parent 1 ID / Passport

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Parent 2 ID / Passport

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School Report (optional)

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