Test Application Note: this form must be completed in full: All changes to be initialed or signed by parent/guardian. Completing the form does not necessarily mean that the learner has been accepted into the SchoolGrade Applied For*Please enter a number from 0 to 12.Highest Grade Passed*Year When Grade Was Passed*Accession No*Learner’s Personal InformationSurname*First Name*Initials*Nick Name:Other NamesDate of Birth* Date Format: YYYY dash MM dash DD Gender*MaleFemaleOtherRace*ID or Passport No*Please enter a number from 13 to 13.Country of Residence*Citizenship*If SA, indicate province of residenceLearner’s Contact InformationPhysical Address*Home Telephone*Emergency Telephone*Learner CellCity/Suburb*Code*Learner Email Address* Home Language*Preferred Language of Instruction*Boarder:YesNoDeceased ParentMotherFatherBothNoneMode of transportReligion*For Grade 1 only: Indicate pre-primary educationNoneNon FormalFormalPrevious School InformationName of Previous School*Previous School Address*Code*Province*Country*Learner’s Medical InformationMedical Aid NumberMedical Aid NameMedical Aid Main MemberDoctor NameDoctor’s AddressDoctor’s TelephoneMedical ConditionReg. Social GrantYesNoSpecial Problems Requiring CounselingDexterity of LearnerRight HandedLeft HandedAmbidextrousLearner’s Siblings at the SchoolNumber of other Children at this schoolPosition in the family (e.g. first)NamesGradePlease enter a number from 0 to 12.NamesGradePlease enter a number from 0 to 12.NamesGradePlease enter a number from 0 to 12.Parent/Guardian InformationTitleInitialsSurname*First Name*Home LanguageGenderMaleFemaleID or Passport NoPlease enter a number from 13 to 13.Account PayerYesNoPostal AddressCity/SuburbCodeOccupationEmployerSurname of SpouseFirst NameOccupation of SpouseLearner resides with this parent/sYesNoSpouse ID NoRelationship to LearnerMarital status of parentCorrespondence DetailsTitleSurname*Postal AddressCity/SuburbCodeHome TelephoneWork TelephoneFax NumberCell NumberSpouse Work TelephoneSpouse Cell Number
