KOWHAI INTERMEDIATE SCHOOL

kowhai.school.nz

KOWHAI INTERMEDIATE SCHOOL

Principal: Paul DouglasPhone: 09 846 7534Fax: 09 846 7918Email: admin@kowhai.school.nzWeb: www.kowhai.school.nzPlease tick appropriate boxIN ZONEKOWHAI INTERMEDIATE SCHOOLENROLMENT 2013OUT OF ZONESAMOAN OPTION !Student’s Full Name: …………………………………………………… ………………………………… …………………………………………First Name Middle Name Legal Family NameKnown As: ………………………………… ………………………………… Date of Birth: ……… / ……… / ………Preferred first Name Preferred Family Name Day/Month/YearCopy of Birth Certificate Supplied: …………………………… Gender: Male / Female!Address: ……… …………………………………………………………………… ……………………………………… …………………………No. Street Suburb Post CodePostal Address: …………………………………………………………………………………………………………………………………………………Current Siblings at Kowhai: ………………………………………… Former Siblings at Kowhai: ……………………………NameNameHome Phone: ………………………………………………………………… Mobile Phone: ……………………………………………………Email Address: ……………………………………………………………… Country of Birth: ………………………………………………Country of Citizenship: …………………………………………………First Language: ……………………………………………………………… Other Languages: ……………………………………………Language spoken at homePrevious School: …………………………………………………………… Class Level at Previous School: ……………………Ethnicity: 1. …………………………………………… 2. ……………………………………………… 3. ……………………………………………Main group you identify with — African, Australian, British/Irish, Cambodian, Chinese, Cook Island Maori, Dutch, Fijian,Filipino, German, Greek, Indian, Italian, Japanese, Korean, Latin American, Maori, Middle Eastern, Niuean, NZ European, Pakeha,Other Asian, Other Ethnicity, Other European, Other Pacific Peoples, Other Southeast Asian, Polish, Samoan, SouthSlav, Sri Lankan, Tokelauan, Tongan, Vietnamese.Does student have any Maori ancestry? Yes / NoIf ’yes’ which is your Iwi? ……………………………………………This section must be completed if the student isNot Born in New ZealandDate Entered New Zealand: ……… /……… /…………Residency Status: NZ Citizenship / NZ PermanentResidence / Student Visa (Please Circle)Refugee Status (if applicable): Quota / Other…………………………………………………………………………………Copy of Documentation Supplied: ……………………This section must be completed if the Parent/sare Not Born in New ZealandParent/s Name: ……………………………………………………Date Entered New Zealand: ……… / ……… / ………Residency Status: NZ Citizenship / NZ PermanentResidence / Student Visa / Work Visa (Please Circle)Refugee Status (if applicable): Quota / Other…………………………………………………………………………………!Country of Birth: …………………………………………………Page 1


ADULT/S WITH WHOM STUDENT LIVES:Caregiver 1: Relationship …………………………………………Surname: ……………………………………………………………………First name: …………………………………………………………………Occupation: …………………………………………………………………Work phone: ………………………………………………………………Mobile phone: ………………………………………………………………Email Address: ……………………………………………………………………Caregiver 2: Relationship………………………………………………Surname: …………………………………………………………………………First name: ………………………………………………………………………Occupation: ……………………………………………………………………Work phone: ……………………………………………………………………Mobile phone: …………………………………………………………………Email Address: …………………………………………………………………………PARENT NOT LIVING WITH STUDENT (If applicable—Required for Board of Trustees Electoral Roll)Relationship: ………………………………………………………………Surname: ……………………………………………………………………First name: …………………………………………………………………Mobile phone: ……………………………………………………………Receive copy of School Report or Notices: Yes / NoAddress: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Email Address: …………………………………………………………………Shared custody: Yes/No ……………………………………………EMERGENCY CONTACTS:It is important that the school is able to make contact with parents/caregivers in an emergency. Please supply two(2) emergency contacts different from adults with whom student lives.Emergency contact 1: Relationship ……………………………Surname: ………………………………………………………………………First name: ……………………………………………………………………Phone: …………………………………………………………………………Mobile phone: ………………………………………………………………Emergency contact 2: Relationship ……………………………Surname: ………………………………………………………………………First name: …………………………………………………………………Phone: ……………………………………………………………………………Mobile phone: …………………………………………………………………MEDICAL INFORMATION:Doctor: ……………………………………………………………………………Phone Number: ……………………………………………………………Medical Problems/Allergies: Degree: (e.g. mild, moderate) Medication Required:………………………………………………… ………………………………………………… ……………………………………………………………………………………………………………… ………………………………………………… ……………………………………………………………Please detail any other prescription medication that the student uses: ……………………………………………………………Ok for School to administer Panadol: Yes / NoIn case of severe medical conditions: Please attach a copy of your child’s medical plan or an action plan (shortsummary) in case of an emergency.LEARNING / BEHAVIOUR NEEDS: Please state any special learning, ability or behaviour needs your child mayhave.…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Other involvement: (RTLB / KARI / ESOL / MOE Special Education / IEP) ……………………………………………………………Page 2


SENSITIVE INFORMATION: (i.e. Custody issues, restricted access etc.)……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Any court orders / protection orders / parenting orders must be supported by copies of relevant documents.Please fill out this section if the student has English as a Second Language:Home Language: ………………………………………………………………… Other Languages Spoken: ……………………………………………Years speaking English (please circle): None / 1 year or less / 2 years / 3 years / 4 years or moreHas the student been schooled in English? Yes / NoIf the student has been schooled in English, for how long? …………………………………………………………………………………………Does the student read and write in English? (please circle) No / very little / yes, at a low level / yes, very goodIs there an English speaker at home? Yes / NoDo you have books in the student’s home language which they can read? Yes / NoDo you have a bi-lingual dictionary? (English and your home language) Yes / NoDoes the student have any learning difficulties or disabilities which may affect his or her progress? Yes / NoAny other comments you wish to make? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Parent / Caregiver Declaration:I declare that:I have completed all relevant sections of the above form and the information supplied is correct.I have supplied copies of documentation where applicable (i.e. Birth Certificate, Passport).I will assume responsibility for the school donation.My child will attend school regularly.My child will abide by the school’s rules, including the wearing of the correct Kowhai Intermediate School uniform.I understand that:The information on this form will be used by the school for educational purposes only.I am giving my permission for the school to include my child in routine health checks when necessary.I am giving my permission to enable the dental authority to access my child’s details.Names, addresses and phone numbers may be released to the BOT.I give permission for:My child’s records to be obtained from their previous schoolMy child’s records to be sent on to their next school upon their leaving Kowhai Intermediate.The information I have provided on this application is true and correct, by virtue of the Oaths and Declarations Act 1957.Signature of Parent / Caregiver: ………………………………………………………………………………… Date: ………………………………………Name: (Please print) ……………………………………………………………………………………………………Page 3


PARENT — CHECK LISTAll relevant documentation has been supplied:Full Birth Certificate or NZ PassportSerial number: ……………………………………………Copy of Proof of address (Power bill/Telephone bill)!Copy of the student’s last school reportCopy of Proof Sensitive Information (court orders, shared custody) if applicableCopy of Medical plan / short summary (severe medical conditions) if applicableIf your child is not born in New Zealand, the following documentation is required!Passport of country of CitizenshipSerial number: ……………………………………………!Student Visa or Permanent Residence Permit or Citizen Certificate:Serial number: …………………………………………Expiry date: ………… / ……… /…………If the child is living with Caregivers other than the biological parents, documentation is requiredto support this arrangement.Legal adoption papers /court order or formal letter from parents explaining living arrangementsFull birth certificate!OFFICE USE ONLY:Date Application received ……… /……… /………Starting Date: ……… /……… /………Year: ……………………………………………Room: …………………………………………Enrolment No: ……………………………Entered in MUSAC: ……………………Entered in ENROL: ……………………ICT Teacher informed: ……………ESOL teacher informed: ……………National Student Number: ……………………………………WITHDRAWN/LEAVERDate: ……… /……… /………Reason: ………………………………………………………………………Intended Destination School: …………………………………Notes: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Page 4

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