Mind Builders Schools :: Building The Future

Mind Builders School

...Building your child for tomorrow's challenges

Apply to Nursery or Primary School

Required Fields are starred (★)

Student Details

★ Surname:

★ Other Names:

★ Gender:

★ Date of Birth:

Age: year(s).

Place of Birth:

★ Religion:

Weight:

Height:

Metres

★ Residential Address:

Home Phone Number:

★ Nationality:

State of Origin:

Local Govt. Area:

★ Class for which Admission is sought:

★ Year and Month of Proposed Entry:

(e.g. 2018 September or 2019 January or 2020 April)

★ Photo of Student:

Current School

Current School (if any):

Reason for leaving Current School (if applicable):

Current Class:

Father's Information

Father's Full Name:

Father's Occupation:

Name and Address of Employer:

Father's Contact Phone:

Father's Email:

Mother's Information

Mother's Full Name:

Mother's Occupation:

Name and Address of Employer:

Mother's Contact Phone:

Mother's Email:

Guardian's Information

Guardian's Full Name:

Guardian's Contact Phone:

Guardian's Email:

Guardian's Address:

Guardian's Relationship to Student:

Fees Correspondence

(This should only be filled, if accounts are not to be sent to Parents or Legal Guardians above. Else, leave blank)

Name:

Relationship to Student:

Address:

Phone:

Email:

Student's Health Record

Please, Specify any Injuries or Medical Conditions the Student has that require Special Attention (if none, leave it blank):

★ Blood Group:

★ Genotype:

Allergies (if none, leave it blank):

★ Family Hospital Name:

★ Family Hospital Contact Phone:

★ Family Hospital Address:

★ Doctor in Charge:

Immunisation

BCG:

Date Administered:

Measles:

Date Administered:

Polio:

Date Administered:

DPT:

Date Administered:

Emergency Contact Inforation

★ Emergency Contact Name:

★ Emergency Contact Phone:

★ Relationship to Student:

★ Emergency Contact Address:

Source of Referral to Mind Builders School

i. Parent ii. Staff iii. Advertisement iv. Others

If either (i) or (ii) above, please provide the referral details below:

Referral's Full Name:

Referral's Contact Phone:

Relationship to Referral:

Admission Form Fees

★ Reference:

★ Date of Payment: