Application Form

Family Name
First Names
Preferred Names
Nationality
Religion
Date of Birth (dd/mm/yy)	Day: Month: Year:
Proposed Level of Entry	Year:
Proposed Year of Entry
	Term 1 Term 2 Term 3 Term 4
Place of Previous Education with Dates
Daughter or Granddaughter of Old Girl If yes: please supply maiden name	HOUSE:
Name of Sibling/s at Chilton Saint James School	HOUSE:
Mailing Address (with suburb)
Home Telephone	Suffix: Number:
Name of Mother	MOTHER / STEPMOTHER/ CAREGIVER

Preferred Name
Occupation of Mother
Home Address (if not as above)
Business Name and Address
Home Telephone	Suffix: Number:
Business Telephone	Suffix: Number:
Mobile Telephone
Email of Mother
Name of Father	FATHER / STEPFATHER/ CAREGIVER

Preferred Name
Occupation
Home Address (if not as above)
Business Name and Address
Home Telephone	Suffix: Number:
Business Telephone	Suffix: Number:
Mobile Telephone
Email of Father
Name of Emergency Contact
Home Telephone	Suffix: Number:
Business Telephone	Suffix: Number:
Mobile Telephone

For the Ministry of Educational statistical returns required of all schools each March and July, we need to have the following information about your daughter:

Did your child have Pre School Education? If 'yes' please indicate whether it was: Kindergarten, Play Centre, Kohanga Reo, Childcare, Montessori or other.	Yes	No

Ethnicity
Which of the following Ministry of Education categories applies to your daughter?

European

Pakeha

Maori

Pacific Island

Asian

Other

Please name the main language(s)
spoken at home:

Medical History:
Illnesses or conditions, including disabilities [eg. Mild/severe asthma, wheelchair]
(if any)

Individual needs / disabilities other than medical.
Contact with SES / Psychologist /
Specialist Learning teachers or organisations.
Please specify:

Immunisation:

(Please tick which is applicable)
My child has been immunised for:

	Yes	No
Hepatitis B
Diphtheria
Tetanus
Whooping Cough
Polio
Measles
Mumps
Rubella
HIB1 (Meningitis)

Enrolment Declaration:

I/ We have read the Business Regulations and agree that, on the acceptance for admission of the Student, we will abide by these terms and conditions.

I/ We agree that the information contained in this form of application may be released to parties outside the School at the discretion of the Principal where it relates to the education, health, welfare or safety of the student.

Where the student concerned in this application is aged 16 years or more, she must agree to the conditions above.

Note: Your application must be accompanied by the Application fee.

I/we have paid the application fee of $100 by direct debit to National Bank Margaret St Lower Hutt account number 06 0529 0035051 00 with a clear indication of who the payment is from.

Parent/Caregiver Agreement

Fees

Application Form