SOUTHAMPTON PRIVATE ACADEMY

2nd Floor, George Corie Centre, 59 Voortrekker Street, PHOTO

P.O. Box 1417 Alberton. Tel: 010 634 0487 WhatsApp 067 356 9025
GDE Reg No. 700401027

Please Attach:
1) Child’s birth certificate/ID Copy 2) Parents’ ID 3) Copy of clinic card
4) Proof of residence 5) Previous school report 6) Previous school transfer card

FOR OFFICE USE ONLY

Date Enrollment For Received: ________________ at Registration is ai :___________________ Grade Applying For:____________________
t nt Amount: _____________________ Year: __________________________

Method: EFT: Rec: Card:

Accepted: _______________ Rejected: ____________________ Reason for Rejection: ____________________________________

CERTIFIED DOCUMENTATION RECEIVED (TICK THE RIGHT BOX)

ID Photo of Learner: Copy of School Report:

Copy of Clinic Card: Copy of legal Guardians ID:
Copy of Birth Certificate: Copy of Psychological / Therapist Reports (IF Any):
Registration Fee Non Refundable): Copy of Medical Aid Card (Both Sides):
Transfer Card / Letter from the Previous School:

WHERE DID YOU HEAR ABOUT OUR SCHOOL (KINDLY TICK IN A BOX BELOW)

Social Media: Flyer: Referred by GDE:

Referred by another school: Web Search: Friend/Family Member:

NB: This form must be completed in full. All changes initiated or signed by parent/guardian.
Completing this form does not necessarily mean that the learner has been accepted into the school.
LEARNERS DETAILS

Surname: ________________________________________________________________________________________________________
Given Names_________________________________________________________ Preferred Name: ______________________________
Date of Birth: DD: ___________ MM:____________ YYYY: ____________
Identification or Passport: __________________________________________________________________________________________
Race: _________________________________________
Country of Residence: ________________________________________
Citizenship: _________________________________________
Gender: _________________________________________
Learners Physical Address: _________________________________________________________________________________
_________________________________________________________________________________
Name of Previous School Attended: _________________________________________________________________________________
Previous School Address: _________________________________________________________________________________
Previous School Contact Details: _________________________________________________________________________________
Previous School Email Address: _________________________________________________________________________________
Current Language of Instruction: ______________________________________________________
Home Language: ______________________________________________________

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For Grade 1 Only (Indicate Pre-primary Education) NONE: NONE FORMAL: FORMAL:
Dexterity of Learner Right Handed: Left Handed: Ambidextrous:

MEDICAL INFORMATION

Name of Medical Aid: ______________________________________ Medical Aid Number: ______________________________

Main Member: ______________________________________ Family Dr’s Name: ________________________________
Doctor’s Contact Number:______________________________________
Doctors Physical Address: _______________________________________________________________________________________
___________________________________________________________________________________________
Medical Conditions: ___________________________________________________________________________________________
Chronic Medication: ___________________________________________________________________________________________
Allergies: ___________________________________________________________________________________________
Special Problems: __________________________________________________________________________________________
Requiring Counselling: ___________________________________________________________________________________________

Contact Person in case of Emergency: ________________________________________________________________________________

NOT A PARENT, Someone Close by: ________________________________________________________________________________
Contact Numbers: _________________________________________________________________________________
Name and Surname: ______________________________________ _________________________________________

SIBLINGS

Number of Siblings in the school: __________ Position in the family: ______________________ (First/Second/Third Etc)
Please Supply full names and surnames Below:

1. ____________________________________________________________ Grade: _________________________________

2. ____________________________________________________________ Grade: _________________________________
3. ____________________________________________________________ Grade: _________________________________
4. ____________________________________________________________ Grade: _________________________________

PERSON RESPONSIBLE FOR SCHOOL ACCOUNT AND CORRESPONDENCE

Title: _________ Initials: __________________ Surname: _____________________________________________

Name:______________________________________ Identity Number:_______________________________________
Email Address: _____________________________________________________________________________________________
Employer: ________________________________________________________________________________________________
Work Telephone Number: ____________________________________________________________________________________
Cellular Number: ___________________________________________________________________________________________
Residential Address: _____________________________________________________________________________________
_______________________________________________ Postal Code: ____________________
Employer Physical Address: __________________________________________________________________________________
City Suburb: ______________________________________________________ Postal Code: _____________________
Occupation________________________________________________________________________________________________

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 PARENT /GUARDIAN INFORMATION – MOTHER

Title: _________ Initials: ________________ Surname: _____________________________________________

Name: ______________________________________ Identity Number:_______________________________________
Race: _____________________________________ Race: _______________________________________________
Email Address: ____________________________________________________________________________________________
Relationship to Learner: ____________________________________ Marital Status: _____________________________________
Employer: _______________________________________________________________________________________________
Work Telephone Number: ___________________________________________________________________________________
Cellular Number: __________________________________________________________________________________________
Email Address: ____________________________________________________________________________________________
Residential Address: ___________________________________________________________________________________
_______________________________________________ Postal Code: _________________
Employer Physical Address: __________________________________________________________________________________
City Suburb: ______________________________________________________ Postal Code: __________________
Occupation________________________________________________________________________________________________

PARENT /GUARDIAN INFORMATION – FATHER

Title: _________ Initials: __________________ Surname: ___________________________________________

Name: ______________________________________ Identity Number:_______________________________________
Race: _____________________________________ Race:________________________________________________
Email Address: ____________________________________________________________________________________________
Relationship to Learner: ____________________________________ Marital Status: _____________________________________
Employer: _______________________________________________________________________________________________
Work Telephone Number: ___________________________________________________________________________________
Cellular Number: __________________________________________________________________________________________
Email Address: ____________________________________________________________________________________________
Residential Address: ___________________________________________________________________________________
_______________________________________________ Postal Code: _________________
Employer Physical Address: __________________________________________________________________________________
City Suburb: ______________________________________________________ Postal Code: _________________
Occupation________________________________________________________________________________________________

GENERAL INFORMATION

With whom does the learner reside? Both Parents: ____________ Mother Only: _____________ Father Only: ____________
Other: (Describe): ____________________________________________________
Religion: _________________________________________________________________________________________
Mode of Transport: _________________________________________________________________________________
Deceased Parent: Mother: ____________________ Father: _________________ None: ________________

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 SECTION A: ADMISSION POLICY & CONDITIONS
The admission policy of our school complies with the requirements of the Gauteng Department of Education. The school gives preference to Learners who reside within the Natural Catchment Area of
the school. This is the area closest to the school by the way of registered roads or access. SOUTHAMPTON ACADEMY does not discriminate on the basis of race, sex or religion. Students are admitted
solely on the basis of availability of places.
 An applicant/learner must comply with the age compatibility of the grade for which he/she is applying.
 Applicants may be required to attend an interview or an entry examination with the Principal where it is deemed necessary.
 The most recent academic report and transfer cards from previous schools will be taken into consideration.
 Non South African citizens require residence or study permits before full registration is confirmed.
 Acceptance of an application for admission to the school does NOT imply acceptance into the school.
 Learners and parents must feel comfortable with the basic ethics of the school before registering.
 The school Uniform policy, Learner code of conduct and other regulations are expected to be observed at all times.
 Registration fees, Admin fees & Library fees are non-refundable. Notice to discontinue studies or deregister from school will only be validated with approval of a parent and Principal. A full calendar
month before the intended date of terminating studies.
“NOW, THEREFORE, THE PARTIES AGREE AS FOLLOWS”:
1.2 Subject to the provisions of the South African Schools Act, 1996, and any Provincial law that may apply, the Parent (s) hereby undertake(s) that, for as long as the Learner attends SOUTHAMPTON
ACADEMY, the school fees and / or any other levies as determined by the school shall be payable.
1.3 The Parent(s) agree(s) to be liable for payment of interest on all overdue amounts, at the maximum rate permitted by law from time to time.
1.4 School fees and/ or levies and interest shall be paid into the School Account and be administered and utilized by the Governing Body of the School at its discretion, but always subject to the
provisions of South African Schools Act and any Provincial laws that may apply.
1.5 If the School institutes legal action for the recovery of any outstanding fees, the Parent(s) agree(s) and undertake(s) to pay all legal costs incurred by the School on the scale as between an Attorney
and his own client including interest or commission.
1.6 School fees can be paid monthly in advance over an academic year period commencing January with final payment on or before 15th December each year. Quarterly or Cash options are also
available.
Full name of Parent (s)/ Legal guardians here in referred to as “the parent (s)”

Father/guardian: ____________________________________________ ID No. ________________________________________________________ Sign_______________

Mother/guardian: ___________________________________________ID No. _________________________________________________________ Sign________________

In respect of the education of (Learner Names) and ID (DOB):

2. REMOVAL OF LEARNERS FROM THE SCHOOL
2.1 The PARENT(S) / GUARDIAN(S) shall give the School at least ONE month written notice of his/her intention to remove a Learner(s) from the school, in which event the school shall upon the
Learner’s departure from the school, refund to the PARENT(S) any tuition fees paid in advance for the portion of the year not utilized. Monies paid for other effects such as library fee, uniform, books etc
may not be refundable.
2.2 If a Learner is removed from the school and NO ’30 days’ notice is given by the parent /guardian, fees paid in advance shall be FORFEITED and accrued fees may still be expected and payable by
the legal parent / guardian. There will be NO expectations from the parent/guardian to be reminded that fees have to be paid. The school shall have the right to hand over any outstanding accounts
without further notice.
3. TUITION OF LEARNERS
3.1 The School shall provide education in accordance with the curriculum and syllabi determined by the Gauteng Department of Education (GDE), but always subject to the requirement of the South
African School Act.
3.2 The parent hereby agrees that no extra tuition shall be expected of the school save for additional support events the school may implement as extracurricular activities.
4. GENERAL
4.1 All registration fees, Library fees, administration fees or any other upfront deposits required are non-refundable.
4.2 The leaner’s failure to attend classes for whatsoever reason shall in no way entitle him/her to a reduction in fees nor will it absolve him/her or other signatories to this document from full liability for the
payment of fees and other charges.
4.3 SOUTHAMPTON ACADEMY shall have the right to alter timetables, opening and closing dates of the school whenever necessary. The School shall NOT necessarily follow all GDE school
calendars/dates.
4.4 No alteration, cancellation, variation or addition hereto, shall be of any force or effect unless reduced to writing and signed by the parties to this agreement, or their duly authorized representatives.
4.5 This document together with the Learner Code of Conduct and any other RULES AND REGULATIONS thereto contain the entire agreement between the parties, and neither party shall be bound by
undertakings, representations or warranties not recorded herein.
4.6 Neither party may cede or assign their rights or delegate their obligations in terms of this agreement without the prior writ ten approval of the other party, which shall not be unreasonably withheld.
4.7 The Parent(s) hereby choose(s) DOMICILIUM CITANDI ET EXECUTANDI for the purpose under this agreement at the address set forth below, and the Parent(s) shall be entitled by notice to the
SCHOOL to change his or her/ their chosen DOMICILIUM provided that the changes shall only become effective 14 days (fourteen) after service of the notice in question.
5. EXTRA CURRICULAR EVENTS
Extracurricular activities at our school shall generally include all school activities conducted outside class for or by learners including but not limited to trips, study excursions, sports events and
competitions. It is necessary for every child to participate in outside class activities for proper mental development. However, “NO LEARNER MAY PARTICIPATE IN ANY ACTIVITY UNLESS THIS
SECTION OF THE FORM IS FULLY COMPLETED AND SIGNED BY THE PARENT/ GUARDIAN”.
I, ..................................................................................................... (Full name and surname], the parent/guardian of…………………………………………………………(Learner name) hereby give
permission for him/her to participate in the school extracurricular activities.
I hereby indemnify and hold the School, its agents, representatives and educators harmless against any claim or demand arising from the death of or injury to my child or any loss of or damage to
property, of whatsoever nature and howsoever sustained, including consequential loss, arising from or occasioned by my child's participation in school extracurricular activities. I also agree that, if in the
opinion of the Principal of the School or his delegated deputy an emergency has arisen and medical treatment be deemed necessary for my child, the Principal of the School or his delegated deputy shall
have the authority (which is hereby delegated to the extent such delegation may be required) to consent to such medical treatment, including surgical l intervention, on my behalf. I further accept that all
precautions will be taken to ensure the safety and welfare of my child and that I will be held responsible for the payment of medical and/or hospital accounts where applicable.
1) Mother’s Signature:__________________________________ Signed and dated at:_____________________________________on this_______________ day, of ________ 20____________.

2) Father’s Signature: __________________________________ Signed and dated at:_____________________________________on this_______________day, of_________20____________.

7. UNDERTAKINGS
THE PARENT(S) / GUARDIAN(S); ..................................................................................................................... (Names) hereby
a) Indemnify the SCHOOL, the members of the GOVERNING BODY, the STAFF and OFFICIALS against any injury, harm or any other loss caused to any person by the conduct of the Learners.
b) Consent to their children participating in School activities, including sport, outings and any other extracurricular activities. The GOVERNING BODY, the STAFF, OFFICIALS and PERSONS ASSISTING
THEM are indemnified against ANY claim for INJURY or LOSS sustained by the LEARNERS and/ or the PARENT (s) while the Learner is engaged in such activities, unless the school, member of the
governing body, the staff, officials or person assisting them acted without authorization or with malicious intent.
c) Undertake(s) to comply with the terms and conditions of the SCHOOL RULES and the CODE OF CONDUCT as amended from time to time. A copy of such rules is issued to the learners and by
request to the parent.
d) Indemnify the school, its employees and officials from liabilities incurred on account of any injuries to, or illness of the Learners and agrees and consents that the school, or any of its educators may
consent to any operation or medical treatment of an URGENT nature for the Learners should such consent be required for medical reasons and should it not be possible for the PARENT(s) to be
approached immediately, all REASONABLE steps to do so having been taken.
e) Accept (s) the Constitution, Rules, Dress Code and code of Conduct of the school and any amendments thereto from time to time.
f) Agree(s) to comply with the regulations pertaining to medical inspections as contained in South African Schools Act and any provincial law that may apply.
g) Agree(s) to have the Learners immunized against all normal infectious and/ or contagious disease and to provide proof upon request.
h) Agree(s) that their children may lawfully be searched for weapons, drugs and may be tested where there is reasonable suspicion of drug use
i) Agree(s) to notify the school immediately of any absence or pending absence of the Learners from the school.
j) Agree(s) to ensure that the Learner is neatly attired in accordance with the SCHOOL UNIFORM REGULATIONS and conducts him/herself in accordance with the CODE OF CONDUCT of the school.
k) Indemnify the school from any liability that may arise due to the learner’s failure to register for department examinations. On receiving a school calendar, I will diarise all closing dates and ensure that
my child is fully registered for the necessary examinations required.
8. BREACH
8.1 Should the PARENT(s) / Guardian(s) fail to pay any amount in terms of this Agreement on the due date, and in such event;
8.2 Legal action shall be instituted against the parent if other means fail.
8.3 Where a parent is not satisfied with the school’s procedures, the school’s enrolment terms, learners’ code of conduct, school disciplinary policy, school refund policy, school uniform policy, school
assessment policy, school attendance policy, other relevant policies and procedures shall be invoked as the first terms of reference to resolve the dissatisfaction. Should parent(s) still not feel satisfied,
then the principal (SMT) will grant leave to the dis-satisfied parent to escalate the issue to the Department of Education’s district or provincial office. Any attempt not to follow this procedure shall constitute
breach of the enrolment terms for SOUTHAMPTON ACADEMY.
9. UNDERTAKING
I , the undersigned hereby declare that:-

1. I have read and understood the policies and procedures on this form and fully comply and submit to the policy and procedures as set out in such document.
2. The authority reserves the right to verify the information given on this form.
3. Any offer of a place will be on the basis that the information supply is accurate.
This Document is to be signed by both parties when learner is brought in for his/her assessment

Name of Parent/Guardian_______________________________ Signature of Parent/Guadian____________________________________Date_________________

Southampton Private Academy___________________________________________________________________________Date: __________________________
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