Demande d`admission - École Al

AL-HOUDA SCHOOL
STUDENT ADMISSION FORM
School year: 2015- 2016
Student ID:_____________________
Family name: __________________________
Date of birth:_____/____/_____
D
M
Medicare number:____________________
First name:______________________
Place of birth:_________________________
Y
Country
/
City
Sex: [ ] Male
[ ] Female
Does your child have chronic health problems?
[ ] Yes
[ ] No
If yes, explain type of problem: ___________________________________________________
______________________________________________________________________________
Grade: __________________________________________
Previous school (if transferred):____________________________________________________
First language: _____________________ Language spoken at home:_____________________
Father
Family name: ____________________________ First name:____________________________
Country of birth: _______________________________________________________________
First language: _____________________
Second language:______________________
Mother
Family name: ____________________________ First name:____________________________
Country of birth:________________________________________________________________
First language: _____________________
Person responsible for child: [ ] father & mother
Second language:______________________
[ ] father
[ ] mother
[ ] other:____
Family address:_________________________________________________________________
Postal code_________________ Phone number (at home):______________________________
Cell. phone (father): ____________________ Cell. phone (mother):______________________
Phone at work (father):_________________ Phone at work (mother): _____________________
Email (father):_________________________ Email (mother):___________________________
Any other information:___________________________________________________________
______________________________
Signature
____________________________
Date
ÉCOLE AL-HOUDA
DEMANDE D’ADMISSION
Année scolaire: 2015- 2016
Code permanent:_________________
N. d’assurance-maladie:_________________
Nom de famille:____________________________
Date de naissance:_____/_____/_____
J
M
Prénom:________________________
Lieu de naissance:______________________
A
Pays
/
Ville
Sexe:
[ ] Masculin
[ ] Féminin
Votre enfant, a-t-il des problèmes chroniques de santé ?
[ ] Oui
[ ] Non
Si oui, lequels ?_________________________________________________________________
_____________________________________________________________________________
Niveau:________________________________________________
Nom de l’école (en cas de transfert):_________________________________________
Langue maternelle:___________________ Langue parlée à la maison: ____________________
Père
Nom de famille:_________________________ Prénom :_______________________________
Pays de naissance:______________________________________________________________
Langue maternelle:____________________
2e langue :____________________________
Mère
Nom de famille:_________________________ Prénom :________________________________
Pays de naissance:_______________________________________________________________
Langue maternelle:____________________
Personne responsable de l’enfant: [ ] père & mère
2e langue :____________________________
[ ] père [ ] mère [ ] Tuteur : ______
Adresse:______________________________________________________________________
Code postale______________No de téléphone (domicile) :______________________________
No de cellulaire (père):__________________ No de cellulaire (mère): ____________________
Téléphone au travail (père):________________ Téléphone au travail (mère):_______________
Courriel (père):_________________________ Courriel (mère):__________________________
Autres informations:_____________________________________________________
______________________________
Signature
____________________________
Date