REGISTRATION FORM AND ENROLMENT CONTRACT
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
St Dominic’s College, Welkom
REGISTRATION FORM
AND ENROLMENT CONTRACT
_________________________________________________
Name of Child
____________________
Admission into Grade
_______________
Place recent
In the Year passport-size
photo here
_______________
Date of Application
Boarding Yes/No
Primary School : PO Box 382,
High School : PO Box 574, Welkom, 9460
Welkom, 9460 South Africa
South Africa Tel 057 352 2686 Fax 057 357 1021
Tel 057 352 3905 Fax 057 353 4631
www.dominic.co.za
headmaster@dominic.co.zaSt Dominic’s College, Welkom
REGISTRATION FORM
ADMISSION PROCEDURE (Any outstanding documents will delay applications)
1. Please return copies of the following with these completed forms:
- Your child’s I.D./ Birth Certificate
- Latest report
- Medical Aid Card (both sides)
- Current School Fees Statement (or 3 months Bank Statements)
- Immunizations Chart (Preschool only)
2. Primary and High School children are required to write a 2-hour Placement Test (English & Mathematics), at a
cost of R200 (Primary) and R500 (High School). This is non-refundable!
3. ONCE ACCEPTED: to secure your child’s space, we require a non-refundable deposit of R1000 (Pre/Primary)
and R1500 (High School) due by the date specified in your child’s Acceptance letter.
4. Boarders are required to pay a full term’s Boarding Fees in advance.
5. Non- South African Citizens will receive a Study Visa Application letter to apply for a compulsory valid Study
Visa.
6. Please use BLOCK CAPITALS to complete this form.
Welcome to our St Dominic’s family!
Select area of Entry (Tick appropriate box) Preschool Primary School High School Boarding
CHILD’S DETAILS
Child’s Surname
Child’s Full Names
Child known as Grade Applying for:
Date of Birth Gender
Identity Number
Home Language Age
Religion
Race
Child’s Cell No.
Child lives with Both parents Only mother Only father Relative Legal Guardian
Other (please state eg Mother and
stepfather, mother remarried etc)
Parents Deceased Mother Father Both None
REFERRAL
Where did you hear about our
school?
If you received a referral from a Name of Parent
parent of a child currently enrolled at
St Dominic’s College, please
indicate Name of Child Grade
…………………………………………………………………………………………………
OFFICIAL USE ONLY (not to be filled in by applicant)
Admission No. Grade & Class
House Entry Date
Mentor/Class Teacher Exit Date
Information captured onto Database by : (Print Name & Date)
Page 1CURRENT SCHOOL INFORMATION
Current School Name
Current School Address
Current School Telephone No.
Name of Head
Current Grade Grade repeated
Has admission to St Dominic’s Has admission to another school
College previously been refused? been refused?
CHILD’S HISTORY OF ACADEMICS, SPORT & LEADERSHIP
Has your child ever required/received learning support? If so, give brief description. (Please attach any reports from associated
practitioner regarding treatment/interventions etc)
Please complete sections where your child has participated and/or achieved in the areas as listed below :
Academic
Sport
Cultural
Spiritual / Community Outreach
Other (eg Leadership)
Page 2FAMILY’S CURRENT STATUS AT ST DOMINIC’S
Name
Relationship Grade
Name
Siblings at St Dominic’s
Relationship Grade
Name
Relationship Grade
Name
Were there any siblings previously
at St Dominic’s?
Relationship Grade & Year
If parent/guardian matriculated at St Name
Dominic’s College, please state
name (ladies - use maiden name) Year Matriculated
Child’s position in the family Eldest 2nd 3rd 4th Youngest
Child’s position at St Dominic’s Eldest 2nd 3rd 4th Youngest
INDEMNITY
I, the undersigned full Name & Surname), __________________________________________________________________________
the Parent/Guardian of (full Name and Surname), ____________________________________________________________________
hereby request that he/she be permitted to participate in curricular and co-curricular activities of the school, including any excursions
arising from these activities.
During these activities I request that the Headmaster and/or staff member act in loco parentis, and I understand that these activities are
undertaken at my child’s own risk, and may include the use of school and/or staff members and/or private person’s transport, and I
hereby, on behalf of myself, my executors, my wife/husband and said child, indemnify, hold blameless and absolve the Board of
Governors, the Headmaster and staff of St Dominic’s College, Welkom, and any other person who may be assisting in the school’s
activities aforementioned, against and from any of all claims whatsoever that may arise in connection with any loss of, or damage to the
said property or person of my child during these activities.
I acknowledge that this indemnity shall be operative and effective from the time and date of signing hereof and shall remain in force until
such time as any claim by my child shall prescribe.
Dated at ____________________________________________ this __________________ day of _____________________________
in the year _________________ .
Signature of Parent/Guardian ____________________________________________________ Date ___________________________
Name of Parent (please print in full) _______________________________________________________________________________
Page 3FATHER/STEPFATHER/GUARDIAN
Surname Title
Full First Names
Marital Status Married to child’s biological mother Re-married Divorced Single, never married
Home Address
Code
Postal Address
Code
ID Number Home Language
Occupation Nationality
Employer Name (Company)
Position held in Company Country where currently stationed
Home Work
Contact details
Fax Cell
Email
Does the learner live with you? Yes / No Are you the legal guardian of the learner? Yes / No
MOTHER/STEPMOTHER/GUARDIAN
Surname Title
Full First Names
Marital Status Married to child’s biological father Re-married Divorced Single, never married
Home Address
Code
Postal Address
Code
ID Number Home Language
Occupation Nationality
Employer Name (Company)
Position held in Company Country where currently stationed
Home Work
Contact details
Fax Cell
Email
Does the learner live with you? Yes / No Are you the legal guardian of the learner? Yes / No
Page 4MEDICAL INFORMATION SHEET (to be completed by ALL applicants)
Name of Medical Scheme
Name of Plan Membership No
Main Member’s Full Names
Main Member’s ID Number
Family Doctor’s Name
Family Doctor’s Tel. No.
Preferred Hospital
Please list any serious medical condition/s (eg asthma,
diabetes, epilepsy etc) which the child may suffer from :
List severe allergies :
List minor allergies :
Describe the nature of the symptoms that present when the condition manifests :
State specific plan of action if your child has a condition that might require immediate assistance by the teacher :
List any emotional trauma the child may have experienced (eg loss of a parent) :
List any physical disabilities or difficulties the child may have :
Is there any additional information you feel we should know about?
Name
Alternative contact if neither father
Tel No.
nor mother available
Relationship to child
NON-SOUTH AFRICAN CITIZENS (see back of registration form regarding eligibility for Immigrant Status)
Date entered South Africa
Country of Birth
Passport Number
Study Permit Number
Special dietary requirements
Page 5SUBJECT CHOICE FORM (to be filled in by Grade 8 – Grade 10 applicants only)
In the Junior Phase (Grades 8 & 9) pupils may choose their second language subject (Afrikaans or Sotho), but all other subjects are
compulsory. In the Senior Phase (Grades 10-12) pupils must select seven subjects, two of which are compulsory. Music is subject to
special entry requirements and will only be permitted at the discretion of the Director of Music.
NAME OF CHILD ________________________________________________________
GRADE _________________________ YEAR __________________
Grade 8 & 9 Grade 10
1 English First Language Compulsory 1 English First Language Compulsory
2 Afrikaans First Additional Language 2 Afrikaans First Additional Language
OR OR
Tick Choice
Sesotho First Additional Language Sesotho First Additional Language Tick One
OR *Business Studies (for
immigrant children ONLY – see note
3. Mathematics Compulsory below. Discuss with Mrs Grimsell)
3 Life Orientation Compulsory
4. General Science Compulsory
5. History Compulsory 4 Mathematics OR
Tick One
6. Geography Compulsory Mathematical Literacy
OFFICE USE ONLY - TEAR OUT
7. Economic Management Sciences Compulsory Physical Science OR
Business Studies
8. Computer Literacy Compulsory
Tick One
9. Arts & Culture (or Introduction to Compulsory
Music Theory – optional)
10. Religious Education Compulsory
6 Accounting OR
Consumer Studies OR
11. Life Orientation Skills Compulsory
Geography OR
Tick One
12. Information Technology Compulsory Dramatic Arts
Please tick:
Are you applying/do you qualify for immigrant status: Yes / No
7 Life Sciences (Biology) OR
*Please Note - Immigrant Candidates :
Information Technology OR
Pupils who enter a South African school for the first time in Grade Tick One
History
7, will have to take Afrikaans/Sesotho, but will be exempt from
Grade 10 onwards, when they will pick up Business Economics
instead. This choice is applicable only to children with Immigrant
Status and replaces a language. Parents must apply for immigrant
status and follow the instructions on the form at the back of this
document.
PLEASE NOTE: Applicants wishing to do Music for matric must have already attained Grade 4 practical and Grade 3 theory by the end of
Grade 9. They need to hand in a separate request for acceptance and be prepared to attend an interview.
MERIT REQUIREMENTS:
Grade 9 pupils must qualify with the following aggregate at the end of Grade 9 in order to do the following subjects:
Mathematics : Attain 60% for Mathematics Accounting : Attain 60% for Mathematics
Science : Attain 60% for Science
Information Technology : Attain 65% for Mathematics and be prepared to write a qualifying test Page 6
Parent’s Name and Surname: ____________________________________________________________________________________
Parent signature: _______________________________________________ Date: ______________________________SUBJECT CHOICE FOR GRADE 11
Please indicate in the box below by means of a tick the subjects you would choose. These are EIGHT subject categories:
NAME _______________________ GRADE _______
Subject Tick choice
Category
1. ENGLISH 1ST LANGUAGE COMPULSORY
2. AFRIKAANS or
SOTHO 1ST ADDITIONAL
LANGUAGE
BUSINESS STUDIES (IMMIGRANTS ONLY – MUST CHECK
WITH MRS GRIMSELL BEFORE CHOOSING)
3. LIFE ORIENTATION COMPULSORY
4. MATHEMATICS or
MATHEMATICAL LITERACY
5. PHYSICAL SCIENCES or
BUSINESS STUDIES
6. ACCOUNTING or
CONSUMER STUDIES or
GEOGRAPHY
7. LIFE SCIENCES (BIOLOGY) or
INFORMATION TECHNOLOGY or
HISTORY
MERIT REQUIREMENTS:
Grade 10 pupils must qualify with the following aggregate at the end of Grade 10 in order to do the
following subjects:
Mathematics : Attain 60% for Mathematics
Accounting : Attain 60% for Mathematics
Science : Attain 60% for Science
Information Technology : Attain 65% for Mathematics and be prepared to write a qualifying test
Applicants taking Physical Science MUST take Mathematics; if they change from Mathematics, they
will automatically be changed to History. They are then required to follow the usual procedure to
change subjects again.
PLEASE NOTE:
Applicants wishing to do Music for matric must have already attained Grade 5 practical and Grade 4
theory by the end of Grade 10. They need to hand in a separate request for acceptance and be prepared
to attend an interview.
Parent’s name and surname: ______________________________________
Signature: ______________________________________Date:________________
Page 7SUBJECT CHOICE INFORMATION (applicable to Grade10 – Grade 12 applicants only)
MERIT REQUIREMENTS:
Grade 9 pupils must qualify with the following aggregate at the end of Grade 9 in order to do the following subjects :
Mathematics : Attain 55% for Mathematics
Accounting : Attain 55% for Mathematics
Science : Attain 55% for Science
Information Technology : Attain 60% for Mathematics and be prepared to write a qualifying test
ENTRY REQUIREMENTS TO HIGHER EDUCATIONAL INSTITUTIONS:
The entry requirements into higher education qualifications based on the new National Senior Certificate (NSC) consist of two
components, namely:
• the level of achievement in the NSC, and
• the types of subjects chosen.
Minimum requirements for obtaining an NSC (General)
Compulsory Home Language at a rating of 3 (40 – 49%)
Two other subjects at a rating of 3 (40 –49 %)
Three subjects at a rating of 2 (30 –39 %)
First Additional Language and Life Orientation MUST be passed
The proposed minimum requirements for admissions to higher education are as follows:
To study for a: you will require a minimum result of
Higher Certificate 3 subjects at a rating of 3 ( 40 –49 %)
4 subjects at a rating of 2 (30 –39 %)
i.e. minimum NSC results
relevant institutional requirements
Diploma 4 subjects at a rating of 3 (40 –49 %)
3 subjects at a rating of 2 (30 –39%)
relevant institutional requirements
First Degree 4 subjects from designated list at a rating of 4 (50 –59%)
Relevant institutional requirements
Designated Subjects offered by St Dominic’s are :
Accounting Geography History Consumer Studies
Information Technology Languages Life Sciences Physical Sciences
Mathematics or Mathematical Literacy Visual Arts Music
Business Economics is only offered to children who qualify for immigrant status.
Entry Requirements for Music as a subject
Children may take Music as a Matric subject; however this is first subject to review by our Director of Music. Applicants must already
have attained Grade 4 practical and Grade 3 Theory by the end of Grade 9, in order to apply. Applicants must hand in a separate
request for acceptance and be prepared to attend an interview.
Entry Requirements for IT as a subject
Children may take IT as a Matric subject; however this is first subject to an entrance test where pupils have attained 60% for
Mathematics at the end of Grade 9. Acceptance to do IT as a Matric subject is at the discretion of the Headmaster.
Page 8DRUG POLICY (applicable to High School applicants only)
We/I the undersigned being the parent(s) and/or custodian of the pupil attending St Dominic’s College High School, do hereby consent
to and authorize blood and urine samples being taken from our/my child at the school’s discretion for the purposes of establishing if
our/my child is taking or has consumed alcohol or narcotics of any kind, provided such samples are taken by a qualified person and
witnessed by a school official.
We/I, the parent, furthermore undertake to place our/my child on a rehabilitation programme if in fact the results of any such test carried
out prove to be positive. We/I also agree to make available to the school a written report of such a rehabilitation programme. If our/my
child is a boarder at St Dominic’s College High School I agree to our/my child being placed on the rehabilitation programme as
determined by the St Dominic’s College from time to time, provided all information is made available to ourselves/myself.
It is understood that if our/my child is tested positive for narcotics or alcohol, we/I shall be responsible for the costs of such tests and for
the rehabilitation programme. An invoice from St Dominic’s College indicating the cost will be sufficient evidence thereof and will be
payable on presentation.
We/I understand, without prejudice to the rights of the Governing Body of St Dominic’s College, that should our/my child be tested
positive for alcohol or narcotics a second time during his educational career at St Dominic’s College, we/I will be requested to remove
our/my child from the school with immediate effect and we/I agree to do so.
We/I furthermore understand, without prejudice to the rights of the Governing Body of St Dominic’s College, that if our/my child is caught
within possession of, or in the act of participating or dealing in narcotics or alcohol, the Governing Body of St Dominic’s College will
request us/me to remove our/my child from the school and we/I will abide by their decision and agree to withdraw him/her from the
school immediately upon such request.
We/I, the parent of ___________________________________________________________________________________________
agree to the above terms and conditions as stipulated in the passage above regarding zero tolerance on drugs.
Father’s Signature : _______________________________________________________ DATE : ___________________________
Mother’s Signature : _______________________________________________________ DATE : ___________________________
Witness 1 : _______________________________________________________ DATE : ___________________________
Witness 1 : _______________________________________________________ DATE : ___________________________
POLICY: FAILURE TO PASS GRADE (applicable to all applicants)
We/I the undersigned being the parent(s) and/or custodian of the pupil attending St Dominic’s College do hereby understand and agree
to the conditions as set out in this policy. Pupils who attend St Dominic’s College, as per school code of conduct, are expected to
practice a high degree of self-discipline, commitment to academics and show proof of effort. Where pupils do not pass a grade at the
end of year, the school reserves the right, at the discretion of the Headmaster, to refuse re-entry into the school for the following year.
We/I, the parent of ___________________________________________________________________________________________
agree to the above terms and conditions as stipulated in the passage above regarding the policy on failure to pass a grade.
Father’s/Guardian’s Signature : _______________________________________ DATE : ___________________________
Mother’s/Guardian’s Signature : _______________________________________ DATE : ___________________________
Page 9CONTRACT OF ACCEPTANCE
This contract is entered into by the parents/guardians of the child and the Board of Governors of St Dominic’s College.
It is recorded that …
1. St Dominic’s College will uphold the values of the Mission and Vision Statement of the College.
2. The parents/guardians accept that St Dominic’s College is a Catholic School which will strive to maintain its Catholic Ethos.
3. The parents/guardians will strive to attend meeting arranged by the College, read written reports/letters and respond to such,
provide suitable conditions for the child to do homework, support the College rules, supply any information to aid the child’s
education process and abide by decisions made by the Headmaster and/or Governing Body regarding school management.
4. St Dominic’s College recognizes the right of the parents/guardians to express views and concerns to recognized representatives
of the College.
5. St Dominic’s College will strive to provide a secure environment for the child, but cannot be held responsible for accidental
injuries.
6. The parents/guardians accept that the College will arrange medical care and/or treatment should the need arise and the
parent/guardian cannot be contacted. Any costs arising will be borne by the parent/guardian.
7. The parents/guardians undertake to pay tuition fees in advance by debit order or stop order only. The parents/guardians will
ensure that the pupil is correctly equipped for school and pay for school/sports uniform, text books and stationery. The
parent/guardian undertakes to pay any additional monies required for educational outings, tours and items specified by the
school.
8. A term’s written notice or a term’s fees in lieu of notice will be required should the parent/guardian wish to withdraw the child
from St Dominic’s College. Failure to do so will result in a notice fee being charged.
9. Payments received after the 7th of the month will incur a penalty.
10. Interest (prime bank rate plus 3%) will be charged on all accounts that are in arrears of 60 days or more. If debit/stop orders are
rejected by the bank, the parents/guardians will pay extra finance charges and face the possibility of his/her child being
suspended from school until the fees are paid.
11. Legal action will be undertaken for all unpaid fees. The expense of such legal action will be recovered from the
parents/guardians, on an attorney and own client scale.
12. The Board of Governors shall administer all funds subject to the provisions of the Private School Act of 1986 (as amended).
UNDERTAKING BY PARENTS/LEGAL GUARDIANS
I, the undersigned __________________________________________________________________________(full Name & Surname),
and
I, the undersigned __________________________________________________________________________(full Name & Surname),
the Parents/Guardians of __________________________________________________________________ (full Name and Surname),
hereby certify we are acquainted with the School Policy and undertake to support the College in the implementation of said Policy and
Rules found in the School Information Guide.
Dated at ____________________________ this ____________ day of _____________________________ in the year ___________
Signature of Mother/Guardian ___________________________________________________ Date ___________________________
Signature of Father/Guardian ___________________________________________________ Date ___________________________
Witness: _______________________________________________ Headmaster: _________________________________________
INSURANCE
The school’s insurance does not cover anything that does not belong to the school. Parents are requested to ensure that their
child/ren’s belongings (eg cell phones, ipods etc) are covered by their own insurance. The school is not liable for damage or theft of
property that belongs to any scholars attending the school.
I, _________________________________________________, parent/guardian of _________________________________________
acknowledge that St Dominic’s College will not held liable for any theft/damage of personal items belonging to my child/ren.
Parent’s Signature: _________________________________________________________ DATE : ___________________________
Parent’s Name (please print): _____________________________________________________________________________
Page 10FINANCE AGREEMENT AND ANNEXURES
Please use block capitals and complete ALL sections of this document.
All information in this document will be regarded as CONFIDENTIAL.
1. ACKNOWLEDGEMENT OF DEBT
I/We, the undersigned, ____________________________________________________________________ (father/mother/guardians)
of (pupil name and surname)___________________________________________________________________________ resident at
_______________________________________________________________________________as domicilium citandi et executandi
(“the Debtor”) do hereby admit that I am liable, and hold myself bound to ST DOMINIC’S COLLEGE (hereafter referred to as the
“Creditor) for the due and proper payment of all school and/or hostel fees due and payable by reason of my/our child/daughter attending
St Dominic’s College (hereinafter referred to as the “Principal Debt”), and furthermore I declare that I am bound by the conditions set out
in the annexure.
ANNEXURE
1.1 The Principal Debt is computed as the cash amount due in terms of the causa of this agreement in respect of all school and/or
hostel fees charged termly in advance.
1.2 The Principal Debt shall be paid as follows:
1.2.1 Cash / Cheque / Debit Order in full payment of the terms fees on the first day of the term.
1.2.2 The signing of a Debit Order authorizing the school to debit your bank account with the annual fees split over an
eleven month period from February to December, except for grade 12, which is a ten month payment period, from
February to November. Debit orders can be arranged for either the 1st or 15th of the month.
1.2.3 School fees are charged monthly in advance as per clause 1.2.2 and payable no later than the 7th of each month.
1.3 Should any payment due in terms of this agreement not be made on due date in terms of clause 1.2 above, the Creditor may
regard the balance of the Principal Debt owing in terms hereof as due and payable immediately, and may issue summons therefore
OFFICE USE ONLY - TEAR OUT
in any competent court without further notice or demand to the Debtor.
1.4 The Debtor hereby expressly renounces the benefits of the non causa debiti, the errore calcull, the revision of the accounts, no
value recorded and all further exceptions of which the meaning is known to the Debtor.
1.5 Upon date of registration of your child, a deposit of R 1 500.00 (High School) or R 1 000.00 (Primary and Preschool) registration
fee is payable in order to secure your child’s place. THIS REGISTRATION FEE WILL NOT BE REFUNDED UNDER ANY
CIRCUMSTANCES.
SIGNATURE DATE
Father (print name)
Mother (print name)
Guardian (print name)
Witness 1
Witness 2
1.6 The Debtor agrees to the jurisdiction of the Magistrate’s Court in terms of section 45 of Magistrate’s Court Act 32 of 1944 for the
recovery of any amount due in terms hereof.
1.7 The Principal Debt shall become due and payable immediately in the event of insolvency (or if the debtor is a company or close
corporation the liquidation) of the debtor, or if the Debtor commits an act of insolvency.
1.8 The Debtor shall pay the costs hereof as well as the stamp duty (unless such stamp duty forms part of the Principal Debt) on
demand. Should the Creditor incur legal costs in the collection of the Principal Debt, the Debtor shall pay such costs—including
those in the nature of Attorney and Client.
1.9 The Debtor shall not be entitled for any reason whatsoever to withhold or defer payment stipulated for in this acknowledgement of
debt.
Page 112. FINANCES AGREEMENT
In signing this registration form:
2.1 I accept the conditions as set out in point 1.1 and 1.2.
2.2 I accept that payment of boarding fees is compulsory. I understand that Boarding Fees must be paid in advance for the term
to the Bursar at the beginning of each term in accordance with the procedures determined by the Board of Governors and I
accept liability therefore.
2.3 I accept that payment of school fees is compulsory. I understand that School Fees must be paid in advance for the month to
the Bursar at the beginning of each month in accordance with the procedures determined by the Board of Governors and I
accept liability therefore.
It is compulsory for both parents to sign this section SIGNATURE DATE
Father (print name)
Mother (print name)
Guardian (print name)
Witness 1
Witness 2
2.4 I accept that should School and/or Boarding fees not be paid timeously, and my account held with the school be handed over
to the School’s Attorney’s for collection, I will be liable for payment of all legal fees, including those in the nature of Attorney
OFFICE USE ONLY - TEAR OUT
and Client, as may be incurred. To such extent, and with a view to fees and legal costs being recovered, I further consent to
the issue of an Emoluments Attachment Order against remuneration as may be receivable by me from my Employer—the
monthly amount payable in terms thereof to be equivalent to the monthly school/hostel fee applicable at the time of the Order
so being issued.
2.5 I accept that failure to make payment on the due date, will result in tuition being withheld from my child, and my child will only
be allowed back at school once all outstanding fees have been settled. Should this happen in two consecutive months, I
accept that I will be requested to remove my child from St Dominic’s College or St Agnes Boarding House.
2.6 I accept that a terms notice, in writing, of intention to withdraw my child from Boarding House is required. Failing this I accept
that I will be held liable for one term’s boarding fees in lieu of notice.
2.7 I accept on behalf of my child, the school and boarding House rules as set out in the General Information Guide, and any
disciplinary action that may be taken by the school arising from offences within the framework of the rules.
2.8 I acknowledge that completion of this form does not necessarily imply confirmation of acceptance of my child at St Dominic’
College. This will be done by letter from the Headmaster.
2.9 I hereby declare that the information given in this document is correct and true.
It is compulsory for both parents to sign this section SIGNATURE DATE
Father (print name)
Mother (print name)
Guardian (print name)
Witness 1
Witness 2
Page 12DEBIT ORDER AUTHORISATION
SECTION A: PUPIL’S INFORMATION
Surname Boarder/Day Scholar
First Names in full Grade
SECTION B : PARENT/GUARDIAN INFORMATION
Parent (Father / Mother / Guardian) – underline which is applicable Cell
Surname Initial Title
First Names
Identity Number
Address
Postal Code
OFFICE USE ONLY - TEAR OUT
Name of Bank Branch Name
Type of Account Current Transmission Cheque (tick which is applicable)
Bank Account Number
(a cancelled blank cheque or a used cheque must be attached in the case of a cheque account)
SECTION C: DEBIT ORDER AUTHORISATION
I, the undersigned, request and authorize St Dominic’s College, Welkom, to draw against my account with the abovementioned
Bank/Building Society (or any other Bank/Building Society or branch to which I may transfer my account) the amount necessary for
payment of the monthly school fees on the first business day of each and every month. All such withdrawals from my account by you
shall be treated as though they had been signed by me personally. Bank/Building Society charges in connection with this instruction are
to be paid by myself.
I, understand that the withdrawals hereby authorized will be processed through a computer system known as the Magtape Service, and
I also understand that if my account is computerized, I will not receive any voucher, but details of each withdrawal will be printed on my
Bank/Building Society statement or in my passbook upon presentation by me for updating.
I further understand that this letter of authorization will be irrevocable during such time as my child/children/wards are pupils at St
Dominic’s College, Welkom and during such time as fees and/or other charges are due and owing by me to the said College.
I further understand and undertake that St Dominic’s College, Welkom, will receive payments in terms of this request without prejudice
to its rights. Should the Bank/Building Society for any reason reclaim from St Dominic’s College, Welkom and paid in terms of this
request pay such amounts over to me, I undertake to refund such amounts to St Dominic’s College, Welkom.
Dated at ____________________________ this ____________ day of _____________________________ in the year ___________
Signature of Person responsible for Debit Order Payment ___________________________ Witness: __________________________
For Office Use Only
Authorized_______________________________________ Year ___________________ Account No ____________________
Page 13THE FOLLOWING PAGES ARE TO BE FILLED OUT BY BOARDING HOUSE
APPLICANTS ONLY
ADDITIONAL MEDICAL INFORMATION
List all surgical procedures child has had (eg
tonsillectomy / appendectomy)
List all medical procedure child has had (eg
gastroscopy)
List any emotional trauma child may have experienced
(eg loss of parent, witness to traumatic event etc)
List any physical problems child may have
List of current medication :
Name of Medication Dose Taken (x) times Reason
per day
State any information that has not been mentioned above, but that is relevant to your child’s health and which is important for the school
to be aware of.
Page 14PARENTAL ACKNOWLEDGEMENT REGARDING MEDICAL LIABILITY
The school will not be liable to pay medical costs for any child. We would also prefer that your child’s medical care be managed via
Private Medical Facilities rather than the less optimal state option. We therefore insist that all boarder children belong to a medical aid,
or at the very least a medical plan. It is preferable that your child is placed on a South African medical scheme as very often schemes
from across our boarders are not accepted, and parents have to pay costs up front in order to claim back these expenses at a later
stage from their own schemes.
There are various options available for medical cover in South Africa. One of these medical schemes is Cape Medical which has a
School Group Scheme for around R800* per child per month. This scheme covers hospitalization and a day-to-day cover for around
R4000* per year (for medical consultations, medicines etc). Other medical schemes include Fedhealth, Bonitas, Medscheme etc. Most
medical schemes are contactable via their websites on the Internet. The school does not source medical aid on your behalf.
If you have your child on a medical scheme or hospital plan, we will require a copy of the medical card. It is your responsibility to ensure
that medical costs such as hospitalization, doctors visits and medication are covered. It is also important that you advise your medical
scheme that your child is attending an education institution in another country so that they are aware of his/her particular circumstances.
I, _________________________________________________, parent/guardian of ________________________________________
belong / do not belong to a medical scheme.
I declare that I understand and accept the following terms and conditions related to my child/ren’s medical care :
a) That I am financially responsible at all times for my child’s medical care, irrespective of whether I have a medical scheme or
not;
b) That I am responsible to provide the school with details of my child’s medical cover, medical history, medical conditions and
any related information the affects the physical, psychological and general medical well-being of my child/ren;
c) That the school will act in loco parentis in all issues with regard to my child’s health and medical well-being in the event that
they cannot get hold of me or my nominated alternative as indicated above;
d) That the school will act in loco parentis for all life-threatening or emergency situations that may arise – these situations might
need immediate action and parents will be informed at the earliest convenience of actions taken;
Parent’s Signature : _________________________________________________________ DATE : ___________________________
Parent’s Name (please print) : ___________________________________________________________________________________
* These costs are estimations which are subject to change and are not fixed.
BOARDING HOUSE CODE OF CONDUCT
I, _________________________________________________, parent/guardian of _________________________________________
acknowledge that I have read and understand the St Agnes Boarding House Code of Conduct and that my child/ren will be expected to
abide by these rules.
Parent’s Signature : _________________________________________________________ DATE : ___________________________
Parent’s Name (please print) : ___________________________________________________________________________________
Page 15FIRST AID CONSENT
By law we are prevented from medicating your child without your consent. Below is a list of medicines which are kept in our first aid
box. Please tick and sign next to those medicines where you grant the school staff consent to administer these medicines to your child.
Name of Medication Indications Yes No Signature
Painamol General pain, aches & fever
Disprin 500mg General pain, aches & fever
Grandpa Powder General pain
Adco-Diclofenac 50mg Menstrual pain, sports injury, painful
muscles, joint pains
Sandoz-Ibuprofen 400mg Toothache, menstrual pain, fever
Besemax Muscular pain
Hyospasmol 10mg Stomach cramps, menstrual pain
Gastron 2mg Acute diarrhoea
Valoid 50mg Nausea and vomiting
Allergex (Tablet or Syrup) Allergies, itchy rash, itchy eyes, runny nose,
insect bite.
Covosan Eyedrops (Antihistamine) Red, itchy eyes, allergic eye reactions, eye
infections
Sulphacetamide Eye Ointment Styes, infected eyes
Dermadine Antiseptic Ointment Wounds, cuts, abrasions, skin infections,
burns
Bactroban Ointment Wounds, cuts, abrasions, skin infections,
burns
Anthisan Cream Allergic skin reactions, stings, bites
Diclohexal Gel Pain and muscular spasm, stiff and injured
muscles, inflammation of muscles
3-in-1 Flu Tablets Colds and Flu
Iodised throat lozenges Sore throat
Sinucon Sinus, blocked nose
Alcolphyllex Cough, bronchodilator
I, _________________________________________________, parent/guardian of _________________________________________
Grant permission to the House Parents/Teacher on duty of the St Agnes Boarding House to administer medicines as per this form, to
my child, upon request.
Parent’s Signature : _________________________________________________________ DATE : ___________________________
Parent’s Name (please print) : ___________________________________________________________________________________
Name of Child : _____________________________________________________________________________________________
Page 16APPLICATON FOR IMMIGRANT STATUS
WHAT IS MEANT BY “IMMIGRANT STATUS” :
Description : An immigrant is :
A. a child or dependant of a diplomatic representative of a foreign government accredited in South Africa;
OR
B. a person who :
first enrolled at and entered a South African school in Grade 7 or a more senior grade;
or
having begun his/her schooling at a school in South Africa, has attended school outside South Africa for two or more consecutive
years after Grade 6 or its equivalent
Children who qualify for immigrant status from the Independent Examinations Board (IEB) have the following choices (depending on ability to cope with
their second language and in consultation with parents and teachers) :
i) Continue with the second language and obtain a full National Senior Certificate in their end of Grade 12 national examinations (this only
with the recommendation of the child’s teacher); or
ii) Drop the second language and take up an alternative subject (compulsory) in order to obtain their National Senior Certificate at the end of
Grade 12.
Parents should note that having a second language has always been a compulsory requirement for passing Matric for entry to University up to 2007;
however from 2008 certain Universities may vary in their requirements for admission due to the new NSC Curriculum. Parents will need to determine these
requirements through direct enquiry at the Universities where your child may apply for future studies.
At St Dominic’s College, we require your child to do a second language in Grade 8 & 9, irrespective of whether he/she qualifies for immigrant status or not.
This serves to afford the child the opportunity to reflect whether he/she has potential to cope with the subject (many potential immigrants do well and
continue with the second language into Matric), and hence whether to continue with the subject in the senior grades or not.
Please fill in the following form and return with the necessary accompanying documentation, together with this registration form.
NAME OF PUPIL
CURRENT GRADE
MY CHILD IS A POSSIBLE IMMIGRANT AND FALLS INTO CATEGORY … A B
I WOULD PREFER MY CHILD TO Continue with Second Language Apply for Immigrant Status
Should you wish for your child to apply for Immigrant Status from the IEB, please fill out the following table and supply ALL supporting reports from each
school your child attended, as well as all forms as per list below. We cannot apply on your child’s behalf without ALL the information.
Name of School Attended & Tel No. Place of School (state Grade Additional Language Attended from Attended to
Province & Country) learned at this school
EXAMPLE : St Dominic’s College (057) 352 Welkom, Free State, South 6 French 13 January 2006 28 November
3905 Africa 2006
Please supply any additional information which might be helpful
Please attach :
• Copy of Page with full details and photograph of Passport (Verified by Commissioner of Oaths)
• Copy of page in Passport showing first entry into RSA for schooling (Verified by Commissioner of Oaths)
• Copy of Study Permit
• Copy of Residents Permit – or cancelled Residents Permit
• Pupil’s History (fill in table above) and copies of all reports
Parent Signature ………………………………………… Date ……………………………………….. Page 17You can also read
