Which class or grade are you applying for?
Little Chicks (> 1 year of age)
Little Ducklings (1 year turning 2 years)
Little Bunnies (2 years turning 3 years)
Little Piggies (3 years turning 4 years)
Reception Year Little Calves (Grade R)
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Which Daily Option are you selecting?
School Hours: Half Day (13:30, no later than 14:00)
Afternoon Care: Full Day (17:00, no later than 17:30)
3 Day Week: Full Day (Only for Chicks & Ducklings)
General Information
Please outline the reasons for choosing Country House School?
How did you hear about us? (Church, advert, social media, word of mouth, etc)
Student Information
Child First Name & Surname
Nationality
Identity Number
Home Language
Population Group: required by Goverment, for statisical reasons (african, white, coloured, etc)
Home Address
Any previous misdemeanors, suspensions or expulsions from previous schools? Attach file if yes
If yes, please upload relevant file
Any Learning Difficulties we should be aware of
If yes, please upload relevant tests or diagnosis
Current School and reason for leaving
Student's Interests, hobbies, talents, sport & cultural participation
Student Medical Information
Medical Aid name and plan
Main Member
Medical Aid Number
Has the learner received all immunizations (if no, please specify reason)
Please upload a copy of immunizations record
Auditory & visual screening dates and outcomes
List of known allergies and any other relevant medical info we should know
General Practitioner
Contact Number of GP
Alternative Contacts
In the event of an emergency, kindly provide 2 alternative contacts (not parental or living with student)
Name & Surname
Relationship to child
Cellular Number
Work Number
Name & Surname
Relationship to child
Cellular Number
Work Number
Parent 1 Information (Or gaurdian/stepparent)
Title, First Name & Surname
Spouse or Partner (only if details are not the same as who appears in Parent 2)
Personal Email Address
Physical Home Address
ID or passport number
Religion
Cellular Number
South African citizen? If no, provide details
Income Tax Number
Please confirm if you are a homeowner or you are renting. If renting, kindly provide the details of your landlord or agency, along with their contact info. Additionally, include the dates from which the contract or ownership began
Employee & Occupation
Commencement (M/D/Y)
Work Contact Details
Work Address
Please confirm your parental status and relationship regarding the student you are applying for. Indicate whether the student resides with you. If you do not live with the student, please specify your relationship: Are you a biological parent, stepparent, legal guardian, or do you have emergency access only? If applicable, elaborate on your involvement and access to the student.
Communication
Parents are urged to be attentive to our designated WhatsApp groups, this is our primary means of communication,
please be diligent in completing and returning newsletters and reply slips
Could you please clarify which number should be designated as the primary contact for communication? Additionally, please specify the WhatsApp contact for classroom groups where teachers or staff can be reached for daily inquiries, general questions, or any concerns. Thank you!
Parent 2 Information (Or gaurdian/stepparent)
Title, First Name & Surname
Spouse or Partner (only if details are not the same as who appears in Parent 1)
Personal Email Address
Physical Home Address
ID or passport number
Religion
Cellular Number
South African citizen? If no, provide details
Income Tax Number
Please confirm if you are a homeowner or you are renting. If renting, kindly provide the details of your landlord or agency, along with their contact info. Additionally, include the dates from which the contract or ownership began
Employee & Occupation
Commencement (M/D/Y)
Work Contact Details
Work Address
Please confirm your parental status and relationship regarding the student you are applying for. Indicate whether the student resides with you. If you do not live with the student, please specify your relationship: Are you a biological parent, stepparent, legal guardian, or do you have emergency access only? If applicable, elaborate on your involvement and access to the student.
Person Responsible for Payment
Title, First Name & Surname
Relationship to the child
Spouse or partner (ONLY if details are not the same as who appears in parent 2)
Personal Email Address
Physical Home Address
ID or passport number
Religion
Cellular Number
South African citizen? If no, provide details
Income Tax Number
Please confirm if you are a homeowner or you are renting. If renting, kindly provide the details of your landlord or agency, along with their contact info. Additionally, include the dates from which the contract or ownership began
Employee & Occupation
Commencement (M/D/Y)
Work Contact Details
Work Address
Entity
Please complete the below section if applicable If a company, close corporation or trust, a resolution authorizing the said person is to sign the application form If the entity fails to pay for any reason whatsoever, the person signing this application form shall be responsible for the payment of any due or outstanding fees to Country House School.
Name of Entity
Type of Entity
Registration Number
Invoices and Statements
Email address invoices & statements should be sent to
In the event of the parents being divorced, the onus rests entirely on the person completing this form to ensure
that the parent and / or guardian and / or other entity stipulated as the fee payer is in terms of the agreement of
settlement and / or court order handed down in respect of such divorce, that the fee payer is correctly stipulated as in terms of such court order. In the event of the person responsible for payment of fees fails to effect payment
of the fees when due, the persons signing this application form shall be responsible for payment of any fees due
to Country House School.
Date
Financial Clearance Certificate
To be completed by previous school if applicable
Full name & surname of student
Schools name
Schools physical address and contact details
School's email address
School's current monthly fees
Please confirm that all financial and contractual obligations were met, adequate notice was given along with a statisfactory behaviour report for the student
Completed by and Designation
Date (M/D/Y)
Consent for Credit Check (Indemnification)
As part of the student's admission process, the school is required to obtain credit report information on the account of the account holder, as may be deemed necessary.
The purpose of the credit report is to assess the account holder’s financial means and ability to satisfy the financial
obligations as set out in the Fee Schedule.
You are required to complete the section below and return to the School’s finance department with your completed
application form.
We the undersigned, hereby authorise Country House School and / or any of its associates to conduct credit enquiries and /
or obtain credit reports in respect of our credit profile, as may be necessary, with the credit bureau of its choice.
Account Holder 1
Account Holder Full Name & Surname
ID/Passport Number
Cellular Number
Home Address
Email Address
Date (M/D/Y)
Account Holder 2
Account Holder Full Name & Surname
ID/Passport Number
Home Address
Cellular Number
Email Address
Date (M/D/Y)
Applications will not be processed unless copies of all documentation requested below are provided
Students unabridged/abridged birth certificate and passport if available
Students latest progress/assessment reports
CEMIS transfer documnet (if applicable)
ID Documents of both parents/gaurdians or person responsible for payment
A certified copy of the latest tax certificate (ITA34 / IRP5)
Furthermore, we the undersigned acknowledge that any Personal Information supplied to Country House School is
provided voluntarily and that Country House School may not be able to comply with its obligations if the correct Personal
Information is not supplied to Country House School. We understand that privacy is important to Country House School
and that Country House School Parties will use reasonable efforts in order to ensure that any Personal Information in their
possession or processed on their behalf is kept confidential, stored in a secure manner and processed in terms of the
Protection of Personal Information Act, No 4. Of 2013 (POPI).
We warrant that all information, including Personal Information, supplied to Country House School is accurate and current
and agree to correct and update such information when necessary.
By submitting any Personal Information to Country House School in any form, we acknowledge that such conduct
constitutes an indefinite unconditional, specific and voluntary consent to the processing of such Personal Information in
the following manner by Country House School and / or its third parties.
Personal Information may be shared by Country House School with the relevant verification information suppliers for
verification, credit check or other legitimate purposes.
A copy of Personal Information kept by Country House School will be furnished to me upon request in terms of the
provisions of POPI. We unconditionally agree to indemnify Country House School against any liability that may result from
the processing of Personal Information and or verification of such personal information.
This includes unintentional disclosures of such Personal Information to - or access by - unauthorized persons, and / or any
reliance which may inadvertently be placed on inaccurate Personal Information provided to Country House School by
myself and / or any third parties.
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