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A. Information of the child

Full Names *

Surname *

Date of Birth *

ID Number

Gender *MaleFemale

Phone *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address

PARENT/GURDIAN 1 CONTACT INFORMATION

Parent / Guardian Name *

Home Phone *

Work/Cell Phone *

Occupation *

Relationship to Student *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address

PARENT/GURDIAN 2 CONTACT INFORMATION

Parent/Guardian Name *

Home Phone *

Work/Cell Phone *

Occupation

Relationship to Student

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address

EMERGERNCY CONTACT DETAIL

Name & Surname

Phone

Name & Surname

Phone

DOCTOR’S INFORMATION

Doctor's Name

Contact Number

Office Phone

MEDICAL INFORMATION

Does your child suffer from a health condition that threatens their life?YesNo

If yes, please explain

Is your child in need of medication at school?YesNo

If yes, please explain

Do you have any other medical issues we should know about your child?YesNo

If yes, please explain

Medical Aid Name

Medical Aid No.

Medical Aid Contact

Main Member

I accept that Certitude Academy: May consult a doctor if I cannot be reached in an emergency Cannot be held responsible for necessary doctor’s fees and medication *

Yes, I agree with the privacy policy and terms and conditions.

ENROLLMENT INFORMATION: TUTORING

Grade

Subject Enrolled forEnglish HL/FALAfrikaansSetswanaMathematics/LitEMSNS and TechSocial ScienceAccountingPhysical ScienceLife SciencesBusiness StudiesGeography

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Dedicated to providing quality education and fostering holistic growth. We strive to create a supportive environment where every student learns and grows.

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12/9 Austin Street,
Renstown Gardens
Hammanskraal
0400

Phone: +27 (012) 004 3755