Application for Admission

SECTION A: LEARNER’S INFORMATION

Learner Surname: (Required)

Learner First Full Names: (Required)

Learner ID No.: (Required)

Learner Passport No:

Learner Date of Birth: (Required)

Learner Race:

Learner Citizenship: (Required)

Learner Province of Residence:
KZNGautengLimpopoEastern CapeNorthern CapeWestern CapeMpumalangaNorth WestFreestate
if NOT SA, indicate country:

Learner Home Language: (Required)
EnglishAfrikaansZuluOther
Learner Home Language, if other Specify:

Learner Religion:

Learner Physical Address: (Required)

Learner Physical Address City Suburb:

Learner Physical Address Code:

Learner Recipient of Social Grant: (Required)
YesNo
Date of registration for Social Grant:

Learner Deceased Parent: (Required)
NoneFatherMotherBoth

Learner Dexterity:
Left HandedRight Handed

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SECTION B: SIBLINGS AT VRYHEID LANDBOU

No of Children at landbou:
123

Position in Family:
1234more

Indicate names of siblings at Landbou:

Name and Surname:

Grade:

Name and Surname:

Grade:

Please indicate other (e.g.cousin):

Name and Surname:

Grade:

Name and Surname:

Grade:

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SECTION C: PARENT INFORMATION

BIOLOGICAL FATHER

Biological Father Marital Status: (Required)
MarriedSingleDivorcedStepfatherDeceasedOther

Biological Father Surname: (Required)

Biological Father First Full Names:

Biological Father Title: (Required)

Biological Father ID No: (Required)

Biological Father Passport No:

Biological Father Home Language:
EnglishAfrikaansZuluOther
Biological Father Home Language if Other Please Specify:

Biological Father Race:

Biological Father Cell Phone No: (Required)

Biological Father Home Tel No:

Biological Father Email Address: (Required)

Biological Father Fax No

Biological Father Physical Address: (Required)

Biological Father City Suburb:

Biological Father Postal Code:

Biological Father Postal Address: (Required)

Biological Father Occupation: (Required)

Biological Father Employer: (Required)

Biological Father Persal No: (If government employed)

Biological Father Work Tel No: (Required)

Biological Father Work City or Suburb: (Required)

Biological Father Responsible for payment of fees: (Required)
YesNo

BIOLOGICAL MOTHER

Biological Mother Marital Status: (Required)
MarriedSingleDivorcedStepmotherDeceasedOther

Biological Mother Surname: (Required)

Biological Mother First Full Names: (Required)

Biological Mother Title:

Biological Mother ID No: (Required)

Biological Mother Passport No:

Biological Mother Home Language:
EnglishAfrikaansZuluOther
Biological Mother Home Language if other please Specify:

Biological Mother Race:

Biological Mother Cell Phone Number: (Required)

Biological Mother Home Tel Number:

Biological Mother Email Address: (Required)

Biological Mother Fax No:

Biological Mother Physical address: (Required)

Biological Mother City or Suburb:

Biological Mother Postal Code:

Biological Mother Postal Address: (Required)

Biological Mother Occupation: (Required)

Biological Mother Employer: (Required)

Biological Mother Persal No: (If Government employed)

Biological Mother Work Tel No: (Required)

Biological Mother Work City or Suburb:

Biological Mother Responsible for payment of fees: (Required)
YesNo

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SECTION D: OTHER PARENT OR LEGAL GUARDIAN

***A certified copy of court order granting such guardianship MUST accompany this form***

Guardian Relationship:
GuardianGrandfatherGrandmotherUncleAuntBrotherSister

Guardian Marital Status:
MarriedSingleDivorcedRemarriedWidowedOther

Guardian Surname: (Required)

Guardian First Full Names: (Required)

Guardian Title:

Guardian ID No: (Required)

Guardian Passport No:

Guardian Home Language:
EnglishAfrikaansZuluOther
Biological Mother Home Language if other please Specify:

Guardian Race:

Guardian Cell Phone Number: (Required)

Guardian Home Tel Number:

Guardian Email Address: (Required)

Guardian Fax No:

Guardian Physical address: (Required)

Guardian City or Suburb:

Guardian Postal Code:

Guardian Postal Address: (Required)

Guardian Occupation: (Required)

Guardian Employer: (Required)

Guardian Persal No: (If Government employed)

Guardian Work Tel No: (Required)

Guardian Work City or Suburb:

Guardian Responsible for payment of fees: (Required)
YesNo

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SECTION E: CURRENT OR PREVIOUS SCHOOL'S INFORMATION

Current School Name: (Required)

Country: (Required)

Province: (Required)

Current School's Tel No: (Required)

Current School's Email Address: (Required)

Current School's Fax No:

Current School's Physical Address: (Required)

Current School's City or Suburb:

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SECTION F: MEDICAL QUESTIONNAIRE

Does the Applicant have Medical Aid? (Required)
YesNo

IF YES PLEASE COMPLETE:

Medical Aid Name:

Medical Aid Main Member Name:

Medical Aid Plan:

Medical Aid No:

***NOTE: When a learner is NOT COVERED by medical aid, the parent/guardian is responsible for ALL medical Expenses**

Doctor's Name:

Doctor's Address:

Doctor's Tel No:

**Please attach a doctors report on the next page if any of the following apply**

Does the applicant have any Allergies? (Required)
YesNo
If YES please indicate:

Does the applicant have any Medical Conditions? (Required)
YesNo
If YES please indicate:

Name any Sport in which the applicant may not participate:

Reason for non participation:

Special Problems Requiring Counseling: (Required)
YesNo

NOTE: THIS SCHOOL IS AN AGRICULTURAL SCHOOL THEREFORE AGRICULTURAL AND ENVIRONMENTAL ACTIVITIES ARE COMPULSORY FOR LEARNERS. PARENTS MUST MAKE CERTAIN UPON APPLICATION THAT THE LEARNER WILL BE ABLE TO ADAPT IN THIS SCHOOL.

**ALSO NOTE THAT CONDITIONS, SUCH AS ASTHMA AND EPILEPSY, CANNOT BE ACCOMMODATED IN THE HOSTEL**

SECTION G: COMPULSORY DOCUMENTS, TERMS AND CONDITIONS:

TERMS AND CONDITIONS:

I have Read and Agree to the Terms and Conditions: (Required)
Yes
Click Here to View T's & C's: Terms and Conditions

COMPULSORY DOCUMENTS:

THE FOLLOWING DOCUMENTS MUST BE ATTACHED:

ID Photo of Applicant: (Required)

Previous year final report (Term 4): (Required)

Copy of latest school report (Term 1-3): (Required)

Copy of both sides of medical aid card:

Proof of Residential Address of Person Responsible for Account, Water & Electricity Bill: (Required)

Immunization Card:

Doctors Report For Allergies:

Doctors Report For Medical Conditions:

The following must be CERTIFIED

UNABRIDGED Birth Certificate: (Required)

ID of both biological parents and legal guardian - if applicable: (Required)

Single Parent

Single Parent Affidavit Stating Accountability:

In The Case of a Deceased Parent

Copy of Death Certificate:

Guardianship

Legal Documents (Court) OR Affidavit from Police Station:

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