| I wish to apply for (name of course): |
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| Number of days my child will attend: |
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| Days attending (please circle): Mon. Tue. Wed. Thurs. Fri. |
| Starting date at NWIS: |
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| Who will accompany child to and from school? |
| Child's Name: |
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| Address: |
| Phone: |
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Fax: |
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| E-mail: |
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Date of Birth: |
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| Age: |
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Nationality: |
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| Boy / Girl (please circle) |
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| Language (s) Spoken at Home: |
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| Father's Name: |
Father's Occupation: |
| Mother's Name: |
Mother's Occupation: |
| Other Children in the Family (name and age): |
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| Emergency Contact Person: |
Relationship to Child: |
| Emergency Phone: |
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| Allergic History: |
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| Any Comments or anything we should know: |
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