Application Form – Bellville Islamic Primary

1. Learner Details

Surname *

First Name(s) *

Known As

GenderMaleFemale

SA ID / Birth Certificate No.

Nationality

Home Language

Grade Applying For *

Year

Previous School

Previous Grade

LURITS / EMIS No.

Reason for Leaving

Passport Photo

No file chosen

Optional. Attach a passport-size photo of the learner.

2. Home Address

Street Address

Suburb

City

Postal Code

Postal Address (if different)

3. Parent / Guardian 1 — Primary Contact

RelationshipMotherFatherGuardianOther

Full Name *

ID Number

Cell No. *

Work No.

Home No.

Email Address *

Occupation

Employer / Company

Work Address

4. Parent / Guardian 2

RelationshipMotherFatherGuardianOther

Full Name

ID Number

Cell No.

Work No.

Home No.

Email Address

Occupation

5. Emergency Contact (other than parents / guardians)

Full Name

Relationship

Cell No.

Home No.

Work No.

6. Medical Information

Medical Aid Name

Medical Aid Number

Doctor’s Name

Doctor’s Contact No.

Known AllergiesEnter "None" if not applicable.

Medical Conditions (asthma, epilepsy, etc.)Enter "None" if not applicable.

Current MedicationEnter "None" if not applicable.

Learning Barriers / Special NeedsEnter "None" if not applicable.

7. Supporting Documents Checklist — please tick what is enclosed

8. Additional Information

Previously suspended or expelled?NoYes

If yes, please give details

Additional comments

Declaration

DECLARATION BY PARENT / GUARDIAN

I / We, the undersigned, confirm that all information provided in this application is true and correct. I / We understand that submission does not guarantee placement, and that the school reserves the right to accept or decline applications in accordance with its admission policy. I / We agree to uphold and support the school’s Islamic ethos, rules, and code of conduct.

Learner Application Form

بسم الله الرحمن الرحيم

Bellville Islamic Primary School

1. Learner Details

2. Home Address

3. Parent / Guardian 1 — Primary Contact

4. Parent / Guardian 2

5. Emergency Contact (other than parents / guardians)

6. Medical Information

7. Supporting Documents Checklist — please tick what is enclosed

8. Additional Information

DECLARATION BY PARENT / GUARDIAN

Bellville Islamic Primary

Programmes

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