Office Use:
Date Enrolled:
Enrolment Number:
ROTO-O-RANGI SCHOOL
Birth Cert. Sighted:
STUDENT ENROLMENT FORM
Room & Year:
Teacher:
Enrol:
Student Details
Family Name: _______________________
First Names: ________________________
Preferred Name: _____________________
Date of Birth: ________________________
Gender:
Year Level:
birth cert. required for 5 yr olds
Boy
Girl
Country of Birth: ___________________ NZ Residency / Citizenship: Yes
No
Home Language: __________________
Previous School or Preschool last attended: ________________________________________
How many years did they attend: _________________________________________________
I wish my child to participate in Religious Instruction ½ hour per week: Yes
No
Choose up to three Ethnic Groups, which you feel your child belongs to:
NZ European / Pakeha
Other European
Please specify: _____________
NZ Maori
Pacific Islands
Please specify: _____________
Asian
Please specify: ___________________
Other
Please specify: ___________________
Iwi 1: _________________________________ (if applicable)
Rohe (Iwi home area): ____________
Iwi 2: _________________________________ (if applicable)
Rohe (Iwi home area): ____________
Contact Details
Caregiver 1:
Relationship to child: ___________________________
Title: _____ (Mr/Mrs/Ms/Miss) First Name: __________________
Last Name:_______________
Home Address: _____________________________________________Post Code: ________
Mail to (if different): __________________________________________Post Code: ________
Phone: (
) _____________
Mobile: ________________
Occupation: ________________________
Work Phone: (
) ___________
Email Address: ___________________________
Contact Details
Caregiver 2:
Relationship to child: ____________________________
Title: _____ (Mr/Mrs/Ms/Miss) First Name: __________________
Last Name:_______________
Home Address: _____________________________________________ Post Code: ________
Mail to (if different): __________________________________________ Post Code: ________
Phone: (
) ______________
Mobile: ________________ Work Phone: (
Occupation: _______________________
) ____________
Email Address: __________________________
EMERGENCY CONTACT NO 1: (When main caregivers cannot be contacted – local only)
Relationship to child: _________________________
Title: _____ (Mr/Mrs/Ms/Miss) First Name: __________________
Phone: (
) _____________
Mobile: ________________
Last Name: ______________
Work Phone: (
) ____________
EMERGENCY CONTACT NO 2: (When emergency contact No.1 cannot be contacted)
Relationship to child: _________________________
Title: _____ (Mr/Mrs/Ms/Miss) First Name: __________________
Phone: (
) ______________
Mobile: ________________
Last Name:_______________
Work Phone: (
) ___________
Student Health Record
Immunizations complete
yes/no
(Please bring a copy of their Immunization Certificate)
Family Doctor: ________________________
Phone: (
) __________________
Allergies: ________________________
Speech: _____________________
Medication: ______________________
Hearing: _____________________
Sight: ___________________________
Dental: ______________________
Other Concerns/Special Needs:_______________________________________________
Other Information (Please attach a separate page if necessary)
Other information from Caregivers: ______________________________________________
Sensitive Information: _________________________________________________________
Any custody arrangement / Access restrictions: _______
Court Order: Yes
No
Other Family Members likely to be attending Roto-o-Rangi School in the near future:
Name: _____________________ D.O.B.: ________________
Name: _____________________ D.O.B.: ________________
I/We acknowledge that the information is true and correct in every particular and can be relied upon by the school.
I/We agree that our child shall abide by all School Rules, Regulations and policies.
I/We understand that the information on this form will be used by this School to maintain appropriate school records
and effective contact with the enrolled pupil’s parents / caregivers.
I/We agree to the school requesting relevant information from other schools for enrolment purposes and class
placement.
I/We consent to the school displaying student work, allowing photographs of student being used outside the school
environment.
I/We understand that the School will take action on my/our behalf in case of sudden illness or injury.
Signature (Parent / Caregiver) _______________________ Date: _____________________
Privacy Statement
The information on this form is collected to form part of the essential information the school holds on your child. The
information collected will be used by the school for the following purposes: enrolling your child at school, assessing
the education needs of your child and ensuring that education services and resources in respect of your child are
provided to the school.
The records made from this information may be viewed on request at the school. The information collected may by
disclosed to education and health sector agencies in accordance with the principles of the Privacy Act. Except with
your specific authorisation, it will not be disclosed to any other person or agency unless such disclosure is authorised
or required by law.
Roto-o-Rangi School Contact Details: 07 827 1727 office@rotoorangi.school.nz