JBAY TECHNICAL COLLEGE: Application Form 2015 JBAY TECHNICAL COLLEGE: LEARNER NAME:__________________________ GRADE: _________________________________

LEARNERS MEDICAL INFORMATION APPLICATION FOR 2015 NON REFUNDABLE REGISTRATION FEE OF R450 PAYABLE ON SUBMISSION OF APPLICATION Banking details: Jbay Acdemy, Standard Bank Branch code:050315, account number: 252461398 Reference – Students name. NAME OF STUDENT N COURSE APPLYING FOR: CURRENT SCHOOL: LEARNERS MEDICAL INFORMATION MEDICAL AID: MEDICAL AID NO: MAIN MEMBER: NAME OF GP: GP TEL: ALLERGIES: IMMUNISATION: SPECIAL MEDICAL PROBLEMS REQUIRING COUNSELLING:

PLEASE INCLUDE THE FOLLOWING STUDENT DETAIL FULL NAME AND SURNAME: DATE OF BIRTH: HOME LANGUAGE: HOME ADDRESS: PLACE OF CHILD IN THE FAMILY (1ST, 2ND, 3RD CHILD): OTHER DETAIL PLEASE INDICATE ANY APPROPRIATE INFORMATION IN THE FOLLOWING AREAS PHYSICAL DISABILITIES: LEARNING DISABILITIES: SOCIAL DISABILITIES: PLEASE INCLUDE THE FOLLOWING COPY OF MOST RECENT SCHOOL REPORT COPY OF ANY PROFESSIONAL REPORTS COPY OF THE BIRTH CERTIFICATE

OTHER DETAIL MOTHER NAME: WORK ADDRESS: WORK TEL: CELL: EMAIL: FATHER NAME: WORK ADDRESS: WORK TEL: CELL: EMAIL: EMERGENCY CONTACT (OTHER THAN PARENTS): STUDENT CELL NUMBER: STUDENT EMAIL ADDRESS:

RESPONSIBILITIES OF THE LEARNER SCHOOL FEES Who will be responsible for the school fees: Payment method School fees are payable in advance by the 1st of each month. The parents must be aware that the school fees are payable in respect of any and each individual academic school year (12 months). SCHOOL FEES: R1250 Parents are jointly and severely liable in the personal capacities for the payments of the school fees. In event of the parents being in default of payment of the school fees-interest at the rate of 20% per annum will be levied on all such amounts which are due as calculated from the date upon which it became payable. Legal steps will be instituted against them without prior notification for the recovery of such arrear fees in which event the parents will be liable for all legal costs and expenses as between attorney and own client including such collection commission which may lawfully become due . Cancellation – 2 months notice . CASH DEBIT EFT RESPONSIBILITIES OF THE LEARNER LEARNER MUST BEHAVE IN ORDERLY MANNER MUST ACCEPT DISCIPLINE WHICH IS NECESSARY FOR THE GOOD FUNCTIONING OF THE ACADEMY ATTEND ACADEMY FAITHFULLY (if not parents are to inform us by either telephone or email) NAME OF PARENT NAME OF PARENT _____________________ ______________________ SIGNATURE OF PARENT SIGNATURE OF PARENT _____________________ _______________________ DATE ______________ SIGNATURE OF JBAY ACADEMY ______________________