Apply Online Apply Online NumberPHASEFoundation Phase Intermediate Phase Senior Phase Fet Phase PERSONAL INFORMATION SurnameNamesName by which learner is calledHome LanguageID NumberSexeMale Female ReligionAfrican Bahai Buddist Christian Hindu Islam Jewish Other Disability (if any)Type of social grantMEDICAL INFORMATION Family doctor/clinicContact NoAllergies (Indicate in RED)Chronic illnessName of Medical AidMedical aid noName of principal member (Medical Aid)Contact personRoad to Health Card shown? Yes No Any indication of problems with regard to Childs growth progress Yes No Prenatal/postnatal information Yes No immunization record (birth to 5 years) Yes No Visual/hearing/height/weight/speech/physical/locomotor screening results Yes No Hospital admissions Yes No Remark Fields with (*) are compulsory.