1. Where teaching is our vocation UCKG DAYCARE CENTRE T/A UCKG Institute for Education - Application Form - 2015 323 Commissioner Street - Fairview - Jeppestown - Johannesburg - 2094 - Tel: 011 614 0602 - fax : 086 575 7374 Child Details: Name Surname Age Gender Date of Birth Nationality M. Language Has he/she had any oparation? Yes No If yes what kind of operation was that? Does he/she suffer from any sickness? Yes No If yes what sickness/Symptoms does he/she have? Does he/she have any allergies? Contacts in case of Emergency Doctor's name Clinic/Hosp Tel/Cell Address Medical Aid number Parents/ Guardians Details Father Name Surname ID Numbers Marital Status Home Address Home Tel Mobile Work Mother Name Surname ID Numbers Marital Status Home Address Home Tel Mobile Work Guardian Name Surname ID Numbers Marital Status Home Address Home Tel Mobile Work Responsibility of who is bringing and collecting your child Name Relationship ID number Contact number Name Relationship ID number Contact number Name Relationship ID number Contact number Waiver I the undersigned parent or guardian of herewith indemnify the principle against any accidents, wich might occur while the said child is in the care of UCKG Institute for Education/ Ikhaya Lezigelosi Childcare Centre. *Referring to the agreement form. Signed on the day of 20____ Parent/ Guardian Signature Witness Signature