Midlands Baby House Midlands Baby House ... - Midrand Estates

Midlands Baby House
Enrolment Form / Inskrywingsvorm 2011
Part 1: Particulars of Child Deel 1: Besonderhede van Kind
First Name(s) Geboorte Naam
Surname Van
Date of birth Geboortedatum
Gender Geslag
Does He/She stay with
both parents?
If no, how often does He/ She see t
he other parent?
Bly Hy/Sy by albei ouers?
Indien nee, hoe gereeld sien Hy/Sy die
ander ouer?
Part 2: Particulars of Parents Deel 2: Besonderhede van Ouers
Please indicate who is responsible
for payment of account
Father / Pappa Mother / Mamma
Dui asb aan wie verantwoordelik is
vir betaling van rekening.
Surname Van
First Name(s) Eerste Name
Identification No. Identiteitsnommer
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Stand No. Erf Nr.
Residential Address Woonadres
Owner/Renting Eienaar / Huurder
Postal Address Posadres
Tel no. (Home) Tel Nr (Huis)
Employer Name Werkgewer
Occupation Beroep
Work Address Werk Adres
Work Tel no. Werk Tel Nr.
Work Fax No. Werk Faks Nr
Part 3: : Medical Aid Particulars Deel 3: : Mediese Fonds Besonderhede
Medical Aid Name Mediese Fonds Naam
Medical Aid No. Mediese Fonds Lid Nommer
Main Member Hooflid
Medical Aid Option Mediese Fonds Opsie
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Part 4: : Medical Practitioner's Particulars Deel 4: : Dokter se Besonderhede
Doctor's name Dokter se Naam
Medical Centre Mediese Sentrum
Tel. Number Tel Nommer
Part 5 : Alternative Contact Details Deel 5 : Alternatiewe kontak besonderhede
Name and Surname Naam en Van
Contact numbers Kontak nommer
Relation to child Verband tot kind
Name and Surname Naam en Van
Contact numbers Kontak nommer
Relation to child Verband tot kind
Part 6: Particulars of Special Medical Care Deel 6: Besonderhede van Spesiale Mediese Sorg
Please note that this is a very important part of your application. We cannot be held responsible for any incidents that may occur due to incorrect
information given. A doctor's certificate is to accompany any threatening allergies.
Neem asseblief kennis dat hierdie 'n baie belangrike gedeelte van die aansoekvorm is. Ons kan nie verantwoordelik gehou word vir enige insidente waar die
verkeerde inligting verskaf is nie. Indien u kind 'n allergie het, moet 'n mediese sertifikaat die aansoek vergesel.
Allergies
Please provide medical
sertificate / Letter from
doctor regarding the allergy
Yes
/ Ja
No /
Nee
Please specify if Yes / Spesifiseer indien Ja
Allergie
Voorsien asseblief mediese
sertifikaar / brief van dokter
rakende allergie.
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Chronic Medication Kroniese Medikasie
Diabetes Diabeet
Asthma Asma
Cardiac Murmur Hartgeruis
Spectacles Brille
Epilepsy Epilepsie
Dietary Requirements Spesiale eetgewoontes
Major Operations Groot Operasies
Behavioural Problems Gedragsprobleme
Immunizations up to date? Immuniserings op datum?
Prem Baby? Vroeg gebore Baba?
Does you child undergo any
special therapy?
Other Medical Details that
we should know
Ondergaan u kind enige terapie?
Ander Mediese Besonderhede
wat ons moet weet
Please note: It is the parents' responsibility to keep us informed if any of the information on this form changes. Midlands Baby House will
not be held responsible if any of the information is incorrect and we are unable to contact you in an emergency. All changes are to be given in
writing to protect yourself as well as Midlands Baby House.
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Part 7: Terms and conditions of enrolment Deel 7: Terme en Voorwaardes vir Aansoek
This document will constitute a legal and binding agreement between Midlands
Baby House and the Parents / Legal Guardians of the child attending the
School
We hereby agree to the following:
1. Child's enrolment will be subject to the conditions stated here-under.
2. Fees are payable in advance, before the fifth day of each month.
3. Payment options are:
- Internet transfer
- Cash
4. To give ONE TERM'S notice if my child will no longer be attending Midlands
Baby House.
5. The parents have read and understood the rules and regulations of the
Midlands Baby house and agree to be bound by the rules, regulations,
policies and procedures of Midlands Baby House.
6.We further give permission to the Owner / Staff of Midlands Baby House
to seek the help of a doctor in an extreme emergency.
To give permission for the administration of anesthetic in a case where
parents or relatives cannot be reached and will accept all expenses
incurred.
7. I, the undersigned legal parent and/or guardian of the above child hereby
indemnifies the Midlands Baby House, it's owners, operators and employees
of any responsibility or claim that may arise by whatever nature due to the
death or injury that may arise out of an illness, accident or injury whilst the
child is at the premises of Midlands Baby House or under the care and
supervision.
I further indemnify them from any responsibility or claim for legal or any
other cost that may arise.
8. To take full responsibility in the case of lost clothing due to the fact that
it was not marked properly.
9. We understand that the registration fee and provisional fee are not
refundable under any circumstances.
Hierdie verteenwoordig 'n volle wettiglike bindende ooreenkoms tussen Midlands
Baby House en die Ouers / Wettige Voodge van die kind wat die skool bywoon.
Ons kom op die volgende ooreen:
1. Die kind se aanvaarding by die skool is gekoppel aand die voorwaardes
en terme hieonder:
2. Fooie is vooruitbetaalbaar, voor die 5'e dag van elke maand.
3. Betalings kan gedoen word op die volgende maniere:
- Internet
- Kontant
4. Om EEN TERMYN se kennis te gee indien my kind nie langer Midlands
Baby House gaan bywoon nie.
5. Ek erken dat ek die Midlands Baby House se reels en regulasies
gelees het en dit verstaan.
6. Ek verleen verder toestemming aan die eienaar van Midlands Baby
House om mediese hulp te soek in buitengewone noodgevalle en ook
toestemming vir die adminitreering van narkose in gevalle waar die
ouers of familielede nie opgespoor kan word nie en aanvaar allekostes
aangegaan.
7. Ek, die ondergetekende wettige ouer/voog van die bogenoemde
kind, vrywaar hiermee die Midlands ay House, sy eienaars, operateurs
en personeel van enige aanspreeklikheid of skadevergoeding van watter
aard ookal en enige geregtelike uitgawes of koste wat mag voortspruit
uit enige eis as gevolg van besering of dood van bogenoemde kind
voortspruitend uit siekteof besering wat genoemde kind mag opdoen
tydens sy/haar verblyf by die sentrum.
8. Aanvaar aanspreeklikheid waar klere weg geraak het omdat dit nie korrek
gemerk is nie.
9. Ek verstaan dat die aansoekfooi en die jaarlikse voorsieningsfooi onder
geen omstandighede terugbetaalbaar is nie.
10. Midlands Baby House is geregtig om hul prokureurs opdrag te gee om
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10. Midlands Baby House shall be entitled to instruct its attorneys to attend
to the collection of outstanding accounts and the parents or guardiens will
be liable for the payment of all costs incurred.
11. I am further aware that FULL SCHOOL FEES ARE PAYABLE IN ADVANCE
IN DECEMBER FOR THE MONTH OF DECEMBER OF EACH YEAR even if my
child is starting at the Pre-Primary the following year.
12. Please note that should the school fee account be in arrears for more than
30 days, the child will not be accepted at school until the account has been
paid and brought up to date.
uitstaande gelde namens hulle in te vorder en dat alle kostes deur die
ouers of voogde gedra sal word.
11. Ek is ook bewus dat VOLLE SKOOLFOOIE VOORUITBETAALBAAR
IS VIR DIE MAAND VAN DESEMBER VAN ELKE JAAR al sou my kind die d
aaropvolgende jaar na die Pre-Primer gaan.
12. Let asseblief op dat indien die skoolfooie rekening agterstallig sou wees
vir meer as 30 dae, sal u kind nie by die skool aanvaar word totdat die re
kening op datum betaal is nie.
I/We the undersigned __________________________ hereby agree that the information given is both true and correct.
Ek/Ons die ondergetekende ______________________ verifieer dat die inligting verskaf korrek en waar is.
Child's name/ Kind se naam: ________________________
DATED AT/GEDATEER
___________________ ON THIS /OP DIE________ DAY OF/DAG VAN _________________.
_____________________ _____________________
Signature of Father
Signature of Mother
Hantekening Vader Handtekening Moeder
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