Centro Educacional Njerenje
CHIREMERA CHIMOIO MANICA MOÇAMBIQUE
E-MAIL: centronjerenje@yahoo.com
TEL: 82 4354190 OR : 82 5541540
APPLICATION FOR ENROLMENT
(TO BE COMPLETED BY THE PERSON WHO HAS LEGAL GUARDIANSHIP OF THE CHILD)
Please complete ALL sections in print.
1. SURNAME___________________________FORENAMES________________________________________
2. Date of Birth _________________ (Please attach photocopy of Birth Certificate) Age________________
3. Male or Female______________ 4. Full or Weekly Boarder/Day Scholar____________________
5. Place required in Grade__________________ 6. Home Language_______________________________
7. MEDICAL RECORDS
Nature of any mental or physical handicap. Immunizations, Allergies etc.
_________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
8. Name of Legal Guardian/Parents_____________________________________________________________
9. Relationship to child_______________________________________________________________________
10. Residential Address______________________________________________________________________
__________________________________________________________________________________________
11. CONTACT DETAILS: (preferably cell phone numbers)
Mother’s Name:_______________ Phone No. __________________ E-mail _______________________
Father’s Name:_________________ Phone No. __________________ E-mail ________________________
Other contact number: Name __________________________ Phone No. _____________________________
12. Any other relevant information:_____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Name ………………………………….Signature:…………………………………….Date…………………….
