ASD Re-registration Form 2023

Learner’s Names: *

Surname: *

Learner’s Nickname:

Date of birth *

ID/Passport Number *

Learner’s Physical Address *

Apt, suite, etc.

Country

City

State

Zip code

Home language *

Religion *

Allergies *

Please select:

Medication *

Given at home

Given at school

Not on Medication

Transport *

RCS transport

Name of other transport

Gender *

Male

Female

Parent/Guardian Details

Parent/Guardian 1

Relation to child *

Name *

ID Number *

Occupation *

Tel No (H)

Tel No (W)

Cell No. *

Email Address *

Residential address *

Apt, suite, etc.

Country

City

State

Zip code

Postal address

Apt, suite, etc.

Country

City

State

Zip code

Parent/Guardian 2

Relation to child

Name

ID Number

Occupation

Tel No (H)

Tel No (W)

Cell No.

Email Address

Residential address

Apt, suite, etc.

Country

City

State

Zip code

Postal address

Apt, suite, etc.

Country

City

State

Zip code

Are both biological parents alive? *

Yes

If no, who has passed away?

Mother

Father

Who has legal custody of the child? *

Social Information

Does the child receive

Child Support Grant

Foster Care Grant

Care Dependency Grant

If there is a current case of abuse please provide us with the following information

Case number

Investigating Officer Contact

Police Station

Cluster of Police Station

SCHOOL FEES CONTRACT FOR ASD

Rules regarding School Fees – 2023

CONTRACT BETWEEN RANDBURG CLINIC SCHOOL AND PARENT/GUARDIAN REGARDING SCHOOL FEES FOR THE YEAR OF 2023

1. The school fee is R1600.00 per month.

2. Exemption of school fees will only be considered on completion of the school exemption forms.

I, *

in my capacity as parent/guardian hereby agree to pay the monthly school fee on or before the 7th of each month, for the understated learner. I acknowledge that making payment on time is an essential part of the agreement. I also acknowledge that it is my responsibility to apply for school fee exemption should the need arise. I give permission, should I apply for exemption for the necessary checks to be done into my financial situation for the exemption process to be objective and fair.

Name of learner *

DETAILS OF PERSON RESPONSIBLE FOR SETTLEMENT OF ACCOUNT

Surname *

Title *

First Names *

ID Number *

Tel No (H)

Tel No (W)

Cell No. (Father)

Cell No. (Mother)

Email Address (Father)

Email Address (Mother)

Parent/ guardian

Reset Signature

please sign here

Date *

Witness

Reset Signature

please sign here

Date *

INDEMINITY FORM

School

I, *

of *

hereby give consent for my child to participate in all sport, cultural and school activities as well as to participate in school excursions.

I accept that all reasonable precautions will be taken for the safety and well-being of my child and will not hold the GDE Officials (Johannesburg North), Educators or Representative responsible for any injury or death resulting from any of these activities. I accept I will be responsible for paying any medical and/or hospital accounts where applicable.

Should medical/surgical treatment be required for my child, I cede my powers as parent/guardian to the GDE Officials (Johannesburg North), Educators or Representative, in my absence as parent/guardian. As far as I know, my child is in good health.

I do, however, request the responsible persons note the following:

(any particulars in connection with child’s health and/or activities/sport he/she may not participate in.) Information required in case of medical/hospital treatment (allergies, asthma, chronic illness, etc.):

MEDICAL INFORMATION

Name of Main Member

Name of employer

Physical address of employer

Apt, suite, etc.

Country

City

State

Zip code

Name of Medical Aid

Medical Aid No

Tel (H)

Father home telephone

Tel (H)

Mother home telephone

Tel (H)

Guardian home telephone

Tel (W)

Father work telephone

Tel (W)

Mother work telephone

Tel (W)

Guardian work telephone

Cell no *

Father cellphone

Cell no

Mother cellphone

Cell no

Guardian cellphone

NB!! Should you not be on Medical Aid, or fail to furnish the particulars, your child will be admitted to the nearest state Hospital – Charlotte Maxeke Hospital or Randburg Clinic.

Name and address of person who we can be contact if you are not reachable:

Name *

Relationship *

Alternate Contact Address

Apt, suite, etc.

Country

City

State

Zip code

Tel/Cell numbers *

Parent/ guardian

Reset Signature

please sign here

Date *

CHRONIC AND ACUTE MEDICATION

Please note:

For the School to adhere to all Health regulations according to administration of any Chronic or Acute Medication, we need all parents to adhere to the following instructions when sending any Chronic or Acute medication to school/hostel.

1. All medication must be sent in its original containers.
2. All medication must be clearly marked with:
– Medicine Name and strength: etc. Ritalin LA 30mg
– Childs Name and Surname: etc. James Mafokeng
– Dosage that must be taken: etc. 30mg or 15ml
– Times/Frequency that Dosages must be taken: etc. At 6h00, 14h00 and 18h00 or 3 times a day.

These precautions are taken to ensure that your child receives the correct medication as well as correct dosages, at the correct times. It is also needed for the nurse on duty to monitor the expiry dates and batch number on the medication container for the safety and health of your child.

Additionally, it is also important to send a new copy of the prescription when any medication changes, dosages changes or administration time changes. Also, a new copy of the prescription is to be provided every 6 months.

Please note: If the child returns to school with medication that does not adhere to the Health Regulation stipulated, the child would be sent back home.

Parent/ guardian

Reset Signature

please sign here

Date *

THERAPY CONSENT FORM

Is your child receiving external therapy? *

Yes

hereby give consent for for Randburg Clinic School Support staff to provide therapeutic services for my child.
These services include but may not be limited to:
• Occupational Therapy
• Speech Therapy
• Counselling
These services are offered at the discretion of the professional, with each child’s best interest in mind.

Parent/ guardian

Reset Signature

please sign here

Date *

Documents

Please upload the following documents:

Learner Birth Certificate

Parent ID

Medical aid card

ASD Parent survey

If we offered hostel accommodation for your child, would you be interested in placing your child in our hostel?

Yes

Parent name

Learner name

ASD RE-REGISTRATION FROM 2023

ASD Re-registration Form 2023

Please select:

Parent/Guardian Details

Social Information

SCHOOL FEES CONTRACT FOR ASD

Rules regarding School Fees – 2023

INDEMINITY FORM

School

MEDICAL INFORMATION

NB!! Should you not be on Medical Aid, or fail to furnish the particulars, your child will be admitted to the nearest state Hospital – Charlotte Maxeke Hospital or Randburg Clinic.

Name and address of person who we can be contact if you are not reachable:

CHRONIC AND ACUTE MEDICATION

THERAPY CONSENT FORM

ASD Parent survey