Student Enrollment form

NZURI PETALS ACADEMY

SUCCESS TO THE UPPER MOST LEVEL

Enrollment form
Please fill in all the details

STUDENT INFORMATION

Surname

First name

last Name

Date of Birth

Student Gender: male female

Class to Join

FAMILY INFORMATION

Mother's/Caregiver's details
Name

Contact details

Mother's email

Occupation

Father's/Caregiver's details
Name

Contact details

Father's email

Occupation

HEALTH,MEDICAL & PERSONAL INFORMATION
Make sure you fill all details

Emergency Contacts

Enter NHIF Number (else write 00)

Does the Student have any pre-existing medical condition (including allergies)
YES
NO

Describe condition (if answer in above question is yes)

Preferred Hospital

hospital contacts

My child is fully immunised against all measles and others immunisable diseases
YES NO
Provide evidence by attaching the immunisation certificate