REGISTRATION FORM - 6201

PLEASE COMPLETE WITH A BLACK PENDO YOU HAVE ANY LEARNERS CURRENTLY/PREVIOUSLY IN THIS SCHOOL? Yes No

Assesment/Tutor name: ____________________ Grade: ________________________________________________________________

LEARNER INFORMATIONLEARNER

Surname:

Nick name:

Date of birth:

ID number:

Nationality: RSA Other:

Religious denomination:

Gender: Male Female

Ethnic group:

Home language: Afrikaans English Other:

Learner's language preference: Afrikaans English

Other:

Learner cell phone number:

Learner e-mail address:

Admission date:

Grade in 6201 :

Years in grade for 6201 :

Years in phase for 6201 :

Pre-primary education attended: Formal Informal

Other:

Attach learner photo:

Photo

NEXT-OF-KIN INFORMATION

Name:

Contact number:

Alternative contact number:

Relation:

OFFICE USE ONLY

number ccountA :

Registration of Date :

residence of Proof : eportR :

card ransferT : Qualification:

FAMILY INFORMATION

Family status: Both parents Single parent - Unmarried

Foster care Childrens home Single parent - Divorced

Other Re-composed Widow/Widower

Parents deceased: Mother Father None

LEARNER HEALTH INFORMATION

Chronic diseases:

Allergies:

Medication:

MEDICAL AID INFORMATION

Name:

Telephone number:

Member number:

Primary member:

INFORMATION OF PREVIOUS SCHOOL/PLAY GROUP/NURSERY

First registration of learner in Gauteng : Yes No

Learner attended school last year: Yes No

If yes, in which Province/Country:

Previous school:

Telephone Number:

Address:

Province:

Highest grade in previous school:

Reason for leaving the school:

1

certificate :Birth parent DI :

PARENT / GUARDIAN 1 INFORMATION

Title:

Full names:

Surname:

Initials:

Nick name:

ID number:

Home language: Afrikaans English Other:

Communication preference: SMS E-mail

Mail By hand

Language preference:

Cell phone number:

Home tel:

Fax:

E-mail:

Residential address:

Postal address:

Occupation status: Own Employer Non-Professional

Own Employer Professional

House wife Part time

Contract worker Pensioner

Student Temporary

Full time Unemployed

Occupation:

Employer:

Work telephone number:

Employer physical address:

Is the learner living with this parent?: Yes No

PARENT / GUARDIAN 2 INFORMATION

Title:

Full names:

Surname:

Initials:

Nick name:

ID number:

Home language: Afrikaans English Other:

Communication preference: SMS E-mail

Mail By hand

Language preference:

Cell phone number:

Home tel:

Fax:

E-mail:

Residential address:

Postal address:

Occupation status: Own Employer Non-Professional

Own Employer Professional

House wife Part time

Contract worker Pensioner

Student Temporary

Full time Unemployed

Occupation:

Employer:

Work telephone number:

Employer physical address:

Is the learner living with this parent?: Yes No

2

Bank

_____________________________________________________________________ number: Account

___________________________________________________________________ name/code: Branch

_______________________________________________________________________ bank: of Name

_________________________________________________________________Account : name holder's

account: the for responsible person for details

ACCOUNTABLE PERSON'S INFORMATION

Parent 1 Parent 2 Other

Only if 'Other', please complete section A or B below:

A) INDIVIDUALTitle:

Full names:

Surname:

Initials:

Nick name:

ID number:

Home language: Afrikaans English Other:

Communication preference: SMS E-mail

Mail By hand

Language preference:

Cell phone number:

Telephone number:

Fax number:

E-mail:

Residential address:

Postal address:

Postal Code:

B) COMPANY / CLOSED CORPORATION / TRUSTTitle:

Name:

Registration number:

Language preference:

Contact number:

Fax number:

Business address:

Postal address:

Postal Code:

3

Bank Account

Name Branch Account _____________________________________________________________________ number:

___________________________________________________________________ name/code:

_______________________________________________________________________ bank: of

_________________________________________________________________ name: holder's

account: the for responsible person for details

I

Signature _______________________ Date: ______________________________________ parent/guardian: of

full

in and

.

correctly completed been has form the that declare_____________________________________________

Subject Choice Gr 10 – 12

Subject, Grade and Language preferred: (please tick with a )

Vak Grade 10 Grade 11 Grade 12 English HL

Afrikaans EAT

Life Orientation

Mathematics

Math Literacy

Computer Application Technology

Physical Science

Life Science

Geography

Tourism

Consumer Studies

Business Study

Hospitality Studies

Documentation:

Registration will not be finalised until all the documents below are received.

1) Certified copy of students ID OR birth certificate 2) Certified ID’s of both parents 3) Proof of residence (FICA) 4) Report from previous school 5) Grade 12, a Grade 10 and 11 report 6) Grade 12 repeater, the previous Grade 12 report 7) Transfer card from previous school(Only applicable for new learners) 8) NCA tests (Only if needed) 9) Qualification of person responsible for students examination

Grade: _______________

Please Subjects

directly. Auxilio contact Please cost. additional an at subject another developing consider however will Auxilio currently. Auxilio by devoloped not are above, table the in listed not are that

note: take

4

2 Môreson Building info@auxilio.co.za 40 van Riebeeck Ave Aux ilio cc Alberton North 2010/105990/23 1453 079 822 0257 In assossiation vir WORD IN TUTH – NPO(PBO)

Financial Agreement with Aux ilio cc for the product(SBA’s) and service delivered for 2016:

A.) Home Schoolers not with registered SACAI assessment centre Gr 1-3 R2 800 Gr 4-6 R5 500 Gr 7-9 R6 000 Gr 10-12 R6 600 (This is for 7 subjects, the SACAI fee is included in this quote) Gr 12 R7 000 (This fee does not include the EWC examination fee or the SACAI registration fee) SACAI registration fee: R600 per subject for 7 or more subjects, not including IT or CAT R700 per subject for less than 7 subjects, not including IT or CAT R700 for IT and/or CAT if student has 7 or more subjects R800 for IT and/or CAT is student has less than 7 subjects The fee will still be determined for any subjects that are not on the 2015 subject list Due date for SACAI fees 30 April 2016(for further information see SACAI’s website) Should a learner have more or less than 7 subjects per year, the following apply for SBA’s supplied by Auxilio: Gr 10-11 R950 per subject(This fee includes the SACAI fee) Gr 12 R1 000 per subject(This fee does not include the EWC examination fee or the SACAI

registration fee, please see the outline of the SACAI fee above)

B.) Home Schoolers with a registered SACAI assessment centre Name of Centre: __________________________________________________ Gr

800 R2 1-3

Gr 4-6 R5 500 Gr 7-9 R6 000 Gr 10 R6 500 (This fee does not include the examination fee of SACAI. The registration fee of R60

is payable directly to the assessment centre.) Gr 11 R6 300 (This fee does not include the examination fee of SACAI. The registration fee of R60

per student and R45 per subject, is payable directly to the assessment centre.) Gr 12 R5 500(This fee ONLY includes Term 1 and 3 tests, June and Prelim exams, of the subjects

that are being developed by Aux ilio, please note that the Gr 12 learner still have to buy the learner support guide(LOG) from SACAI, at R150 per subject .)

Should a learner have more or less than 7 subjects per year, the following apply for SBA’s supplied by Auxilio: Gr 10 R930 per subject(This fee does not include the examination fee of SACAI) Gr 11 R900 per subject(This fee does not include the examination fee of SACAI) Gr 12 R790 per subject (This fee ONLY includes Term 1 and 3 tests, June and Prelim exams, of

the subjects that are being developed by Aux ilio, please note that the Gr 12 learner still have to buy the learner support guide(LOG) from SACAI, at R150 per subject.)

Aux ilio cc bank details:

Auxilio Academy Standard Bank Alberton 020 633 831

PAYMENT OPTIONS:

Please mark the correct option:

A.) Full payment R____________________________ (This option is compulsory for Gr 1-3 pupils)

OR B.) Instalment: (This option is not applicable to Gr 1 – 3)

25% of R_________________________ with registration and the balance of R _________________ payable over eight (8) months from February – September before or on the seventh (7) day of each month. All accounts are sent by e-mail. E-mail address for account:__________________________________________________

Agreement between Aux ilio and_______________________________________________(Name of

parent/guardian) with regards to the payment:

a) I_________________________________parent/guardian of _______________________

(child’s name) accept responsibility for the payment of support and product fees for 2016. I agree to

pay the fees before or on the seventh (7) day of each month.

b) I understand that Aux ilio cc will take the necessary legal steps to recover any outstanding fees.

c) I accept responsibility to inform Aux ilio cc should my child terminate his/her studies. I understand that

I buy a support SBA in hardcopy to help me in homeschooling. Aux ilio cc will not refund any monies.

SBA’s are required by law.

d) I declare that the form has been completed correctly. I have read and understand the acceptance

requirements.

e) I declare to capture all practical work on DVD and to courier it for assessment and moderation. This is

for student/parents own cost.

f) I/We the parents/guardian of _______________________________ undertake to honour the

agreement as set out above.

Full names of Person Responsible for account:____________________________________________

Signature of Person responsible for account: _____________________________________________

Date:__________________________________

ID number of person responsible for account:_____________________________________________