Registration Form
Student Information
Surname:
First Names:
Birthdate:
Gender:
Male
Female
Nationality:
ID / Passport No. :
Mother's Surname
(If different from Student's):
Father's Surname:
Guardian's Name:
Telephone Numbers
Tel No:
Student Cell:
Student Home No:
Mother's Cell No:
Mother's Home No:
Mother's Work No:
Mother's Fax No:
Father's Cell No:
Father's Home No:
Father's Work No:
Father's Fax No:
Guardian's Cell No:
Guardian's Home No:
Guardian's Work No:
Guardian's Fax No:
Addresses
Postal Address
Residential Address
Email Address:
Medical Information
Allergies / Conditions
Medical Aid:
Medical No:
Doctor's Name:
Doctor's No:
Payment Plan method & Agreement
Option 1
Paid over
Select
1
2
3
4
5
6
7
8
9
10
11
12
instalments. 1st Payment:
R
.
Thereafter, payments of
R
of the first of the month from
December '05
January
February
March
April
May
June
July
August
September
October
November
until
January
February
March
April
May
June
July
August
September
October
November
Note
Payments are due on the first of the month
Option 2
Registration fee:
R
2, 500.00 plus balance over equal instalments on the 1st day of each term or before of
R
Option 3
Early settlement with applicable discount (10% if paid before 28 February 2006)
Registration fee must still be paid on registration, but will be deducted from balance outstanding and discount applied if you choose this option
Method of Payment:
Cash
EFT
Cheque
Stop Order
Bank Deposit
Person Responsible for Payment of Account
Title:
Initials:
Surname:
Relationship:
Home Tel:
Work Tel:
Cell No:
Fax:
E-mail:
Postal Address
ID No:
I declare that all the particulars are correct and undertake to update any changes of address or contact numbers. I agree to pay all fees due for the duration of the student's attendance at Greenwich College.