Enrollment Form

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Name
Gender
Record of immunization: Please tick as appropriate, Has your child been - (a) Immunized against Small Pox?
(b) Immunized against Measles?
(c) Immunized against Whooping Cough?
(d) Immunized against Polio?
(e) Immunized against Tetanus?
(f) Immunized against Tuberculosis?
In case of emergency, do you permit the school to take your child to the clinic?
FAMILY BACKGROUND - Applicant lives with
Are Parents Separated/ Divorced?
Confirm Information