ADMISSION DATE______________________

ADMISSION NUMBER _________________________

FULL NAME  _________________________________________________________________________

DATE OF BIRTH________________________

NUMBER OF CHILDREN IN FAMILY _______

ETHNIC GROUP________________________

PLACE IN FAMILY ______________________

FATHER/GUARDIAN NAME _______________________________________________________________

MOTHER/GUARDIAN NAME ______________________________________________________________

HOME ADDRESS (1) ____________________

_____________________________________

HOME ADDRESS (2) ___________________________

_____________________________________________

HOME PHONE_________________________

HOME PHONE ________________________________

WORK PHONE _________________________

WORK PHONE ________________________________

EMERGENCY CONTACT ____________________________  PHONE ____________________________

                                           ____________________________  PHONE____________________________

LAST SCHOOL ATTENDED ____________________

CLASS ________________________________

ADDRESS  _____________________________________________________

NUMBER OF PRESCHOOL CHILDREN IN FAMILY ____________________

DATES OF BIRTH ____________________________________________________________________

BIBLE IN SCHOOLS?    YES / NO

DO YOU WISH TO USE THE SCHOOL BUS?  YES / NO

HEALTH:  Does your child have any problems with the following?

FAMILY DOCTOR  _________________

Asthma _________

Sight ________

Allergies ________

Speech ______

Hearing _________

On any medication ____________________________

Other   ____________________________________

PREVIOUS DENTAL CLINIC ___________________________

PRESCHOOL INVOLVEMENT (Playcentre, Kindergarten, Te Kohanga Reo)

___________________

HOBBIES/ ACTIVITIES/ CLUBS   _________________________________________________________

Has your child received any special help in the past?

Eg:  Reading Recovery_______,   Speech Therapy ________,   Other__________________________

If I am unable to be contacted in an emergency I DO / DO NOT consent to my child receiving medical attention.

I give permission for student records to be requested.

I understand that this information will remain confidential to Walton School.

SIGNED: _____________________________________________________________ (Parent/ Guardian)