For office use - Year 7 / 8 Room ______
Student Details
Date of Birth
Address __________________________
Surname _________________________________
Legal Surname ____________________________
Copy of NZ Birth
Certificate OR
1st Name ________________________________
passport to be
Postcode __________
2nd Name ________________________________
Students NOT N.Z.
Preferred Name ___________________________
born must also
Phone ______________________
attach their birth

Names of any brothers or sisters who are or have

certificate along
with the Passport
attended Papatoetoe Intermediate –
Email you would like school correspondence to
Name Year attended
_____________________________ _______
_____________________________ _______

Ethnicity _______________________________ Main language spoken at home ________________________ Country of Birth ___________________________________ If Maori please state your Iwi Affiliation ________________________________________

Mother/Guardian Details
[if not Mum please indicate relationship e.g. Step Mother, Aunt, Guardian] ________________________
Title ____ First Name _______________________ Surname _______________________________________
Occupation ____________________________ Work Phone _______________ Cel __________________________ Address – [if different from above- please include Postcode] __________________________________________________ _____________________________________________________________________________________________

Father/Guardian Details
[If not Dad please indicate relationship e.g. Step Father, Uncle, Guardian] _______________________
Title ____ First Name _______________________ Surname _______________________________________
Occupation ____________________________ Work Phone _______________ Cel __________________________ Address – [if different from above- please include Postcode]] __________________________________________________ _____________________________________________________________________________________________

Emergency Contact Details
[Please indicate relationship e.g. Friend, Neighbour, Grandparent] ____________________________
Title ____ First Name _______________________ Surname _______________________________________
Home phone ____________________ Work Phone _______________ Cel _____________________________ Previous School ______________________________________________________ Medical Details
Doctor’s Name ________________________________________ Phone _____________________ Medical Conditions and associate procedures [if any] ______________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Please supply details of any condition that may call for special steps to be taken _________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
Access Restrictions
Is anyone to be denied Access to your child? If yes please state who and supply any documentation.
___________________________________________________________ Documents are attached – Yes/No
If NOT New Zealand born please answer the following questions.
Date of arrival in New Zealand ______________________________________

Can we administer the following if required?

Permission to -

The personal information provided in this application will be used for school management purposes, and appropriate statistical returns.
▪ Photos of students’ and their work may be published on the school website. ▪ Pupils change school and are also promoted to secondary schools. Information is passed on to the new schools. ▪ I/we agree to pay for any charges the board may wish to make for any specific school activities.
Signed _______________________________________________ Parent/Guardian

People who use false addresses or ‘addresses of convenience’ to get into their preferred school ‘in zone’ –
when they are NOT – will have their children’s enrolment cancelled.


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Gulf Coast Regional Blood Center SOP 3320 series 1400 La Concha Lane, Houston, TX 77054 Phone: (713) 790-1200 Fax: (713) 790-1007 Page 1 of 2 Health History Reference Please tell us if you are now taking or if you have EVER taken any of these medications: Proscar© (finasteride) – usually given for prostate gland enlargement Avodart©, Jalyn (dutasteride) – usually giv

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