Heaton Normal Intermediate Enrolment Form

Student Details

* First Name (legal)

Middle Name(s)

* Family Name (legal)

Preferred First Name (if different from first name)

Preferred Last Name (if different from last name)

* Gender

Male Female

* Date of Birth

First Schooling date (This is the date your child commenced their schooling. i.e. 5th birthday)

Please indicate whether you are submitting an in zone or out of zone application.

In Zone Out of Zone Priority

Current School and School Address

Current Year Level

Ethnicity

Country of Origin

Languages Spoken at Home

Date of arrival in NZ (if born overseas)

* Ethnic Origin 1

Ethnic Origin 2

Ethnic Origin 3

IWI 1

IWI 2

IWI 3

* Citizenship

Student's Address

* Address Line 1

Address Line 2

* Address Line 3

Postcode

Home phone number

Mobile phone number

Living Arrangements

Who does your child live with? (e.g. Mother and Father, Father and Stepmother, Designated Caregiver etc)

Please indicate with whom the student lives.

Are there any Court Orders / Access Arrangements the school should be aware of?

Please add any access arrangements.

Sibling/Parent has attended Heaton Intermediate?

No Yes

Please state below full name(s) of sibling(s)/parent(s) and dates attended Heaton

(2)

(3)

Contact 1

This is the Primary Contact for this student.

* Contact 1's First Name

* Contact 1's Last Name

* Contact 1's Address Line 1

Contact 1's Address Line 2

* Contact 1's Address Line 3

Contact 1's Postcode

Contact 1's Email Address

Contact 1's Mobile Phone

* Contact 1's Home Phone (please enter Mobile Phone Number if no Home Phone)

Contact 1's Work Phone

Contact 1's Occupation / Work Place

Contact 1's Relationship to Learner

Caregiver Father Grandfather Grandmother Mother Other

Contact 1's Relationship (if other)

Contact 2

This is the Secondary Contact for this student.

Contact 2's First Name

Contact 2's Last Name

Contact 2's Address Line 1

Contact 2's Address Line 2

Contact 2's Address Line 3

Contact 2's Postcode

Contact 2's Email Address

Contact 2's Mobile Phone

Contact 2's Home Phone

Contact 2's Work Phone

Contact 2's Occupation / Work Place

Contact 2's Relationship to Learner

Caregiver Father Grandfather Grandmother Mother Other Stepfather Stepmother

Contact 2's Relationship (if other)

Contact 3

Contact 3's First Name

Contact 3's Last Name

Contact 3's Address Line 1

Contact 3's Address Line 2

Contact 3's Address Line 3

Contact 3's Postcode

Contact 3's Email Address

Contact 3's Mobile Phone

Contact 3's Home Phone

Contact 3's Work Phone

Contact 3's Occupation

Contact 3's Relationship to Learner

Caregiver Father Grandfather Grandmother Mother Other Stepfather Stepmother

Contact 3's Relationship (if other)

Emergency Contacts

This must be a person other than Contact 1 or Contact 2.

Emergency 1 First Name

Emergency 1 Last Name

Emergency 1 Mobile Phone

Emergency 1 Home Phone

Emergency 1 Relationship to Student

Emergency 2 First Name

Emergency 2 Last Name

Emergency 2 Mobile Phone

Emergency 2 Home Phone

Emergency 2 Relationship to Student

Medical

Doctor (please enter Name, Medical Centre and Phone No.)

Does your child have any SEVERE Medical Conditions the school must know about?

Please leave blank if not applicable.

Does your child have any other Medical Conditions?

Please leave blank if not applicable.

Allergies?

Please leave blank if not applicable.

Medications?

Please leave blank if not applicable.

Do you have a Health Care Plan written by your doctor or specialist?

No Yes Not applicable

My child's immunisations have been completed to date.

Chosen not to immunise Partly Unknown Yes

Consent

I/we give permission for my/our child's photograph to be used in positive school publicity e.g. newsletter?

No Yes

I/we agree to my/our child's name, work and/or photograph being used on the school website or other websites as recorded in the school policy?

No Yes

I/we understand that the school will take action on my behalf in the case of sudden illness or injury.

No Yes

Other

Agreement:

1. I/we understand that under the Privacy Act 1993, personal information included on this form may be disclosed, if in the student’s interests, to education agencies with the statutory right to obtain such information.

2. I/we have an obligation to inform the school of any changes to the personal details about this student.

3. I/we will take responsibility for the payment of repairs or damage to school property that our son/daughter carelessly damages.

4. I/We understand personal property brought to school is at own risk.

5. I/We have read and understood the Board Policy: School Community Code of Responsible Conduct.

In Zone Declaration:

The address given at the time of application for enrolment must be the student’s usual place of residence when the school is open for instruction. This means that if you move to an out-of-zone address before your child’s first day of attendance at the school, your child will not be entitled to enroll at Heaton Intermediate.

The Ministry of Education advises that parents should be warned of the possible consequences of deliberately attempting to gain unfair priority for enrolment by knowingly giving a false address or making an in-zone living arrangement which they intend to be only temporary; for example: Renting accommodation in-zone on a short-term basis; Arranging temporary board in-zone with a relative or family friend; or Using an in-zone address of a relative or friend with no intention to live there on an ongoing basis.

If the school learns that a student is no longer living at the in-zone address given at the time of application for enrolment, and has reasonable grounds to believe that a temporary in-zone residence has been used for the purposes of unfairly gaining priority in enrolment at the school, then the board can review the enrolment. Unless the parents can give a satisfactory explanation within 10 days, the board may annul the enrolment. This course of action is provided for under Section 110A of the Education Act 1989.

I confirm that the address which I have provided to the school will be the student’s usual place of residence when the school is open for instruction. I will advise the school immediately of any subsequent change of address.

* I confirm that I have read and understand the Agreements and Zone Declaration above.

Yes

2020 Heaton Normal Intermediate School Enrolment Form

This can be either:

I/We have read and understood the: Board Policy: School Community Code of Responsible Conduct

Please note: If you are wanting to enrol your child for the remaining terms in 2019, please do not use this online form. Contact the school office.

This is the Primary Contact for this student.

This is the Secondary Contact for this student.

This must be a person other than Contact 1 or Contact 2.