To submit at the school

School year 2019-2020

REGISTRATION FORM

Registration form should be submitted to the office, before May 31, 2019,
accompanied by the registration fees for the year 2019-2020,the school
insurance and the documents to be provided. One recent

picture
 First registration  Re-registration

FOR NEW ARRIVALS , DATE OF REGISTRATION TO E.F.S.R. : .....................................................

1. Registration for class : ................................

Family name: ...............................................................................................................................................................................

Name: ............................................................................................................................................................................................

Date of birth: .................................................................................................................................................................................

Gender:  Male  Female

Place of birth: ...............................................................................................................................................................................

Country of birth: ...........................................................................................................................................................................

Nationality: ............................................................... Specify if dual nationality: ....................................................................

Native language: ..........................................................................................................................................................................

Other spoken languages: ...........................................................................................................................................................

Most widely spoken language: .................................................................................................................................................

Spoken language in the previous school year: ......................................................................................................................

Address in Siem Reap: ...............................................................................................................................................................

.........................................................................................................................................................................................................

2. Father or legal guardian

Family name/name: ....................................................................................................................................................................

Nationality: ............................................................. Specify if dual nationality: ......................................................................

Native language: ....................................................Language spoken with the child: ..........................................................

Profession: ....................................................................................................................................................................................

Company name: ..........................................................................................................................................................................

Business phone number: ............................................................... Cell phone: .....................................................................

E-mail: ............................................................................................................................................................................................

Parent’s signature: ................................................................................................................

 To submit at the school
3. Mother or legal guardian
Family name/name: ....................................................................................................................................................................

Nationality: .................................................................Specify if dual nationality: ...................................................................

Native language: ...................................................... Language spoken with the child: .......................................................

Profession: ....................................................................................................................................................................................

Company name: ..........................................................................................................................................................................

Business phone number: ............................................................... Cell phone: .....................................................................

E-mail: ............................................................................................................................................................................................

4. Family situation
In case of separation or parents’ absence, with whom should the school communicate?

 Father  Mother  other (give details below)

Family name/name: ....................................................................................................................................................................

Relationship to the child, if not mother or father as indicated above ...............................................................................

Phone number: ............................................................... E-mail: ...............................................................................................

5. Emergency contact

Name (father or legal guardian): .......................................................... Cell phone: ..............................................................

Name (mother or legal guardian): ........................................................ Cell phone: ..............................................................

Family/Neighbour/Friend/Other: .......................................................... Cell phone: .............................................................

(Specify name and relationship to child)

6. Educational background

School year School attended Grade

2018-2019

2017-2018

2016-2017

For a new registration of a child already enrolled in another school, please include:

1. Certificate of education: cancellation

2. The school report

7. Schooling of siblings

Name Family Name Date of birth School attended Grade

Parent’s signature: ................................................................................................................

 To submit at the school
8. Authorisation for the EFSR’s school directory circulated within the school
 I authorise the establishment to publish the contact details of the family (address, phone number, e-mail
address) in the school directory.

 I don’t authorise the establishment to publish the contact of the family (address, phone number, e-mail
address) in the school directory.

9. Authorisation for the EFSR’s blog and website

 I authorise the establishment to publish the picture of my child on the school’s blog and website.

 I don’t authorise the establishment to publish the picture of my child on the school’s blog and website.

10. Authorisation for the field trip (temples, museum,…)

 I authorise my child to participate at the field trips organized by the EFSR
 I don’t authorise my child to participate at the field trips organized by the EFSR

11. Insurance
 Helth insurance

I hereby certify that I have purchased an health insurance for my child,

 yes Company ……………………………………………………………………………………………………………………………………………………………….…

Policy n° …………………………………………………………………………………..… phone number : …………………………………………………..………..

Proof of policy must be provided.

 no

 Civil liability insurance

I hereby certify that I have purchased a civil liability insurance for my child,

 yes Company ………………………………………………………………………………………………………………………………………….………………………

Policy n° ……………………………………………………………………………………… phone number : …………………………………………….……………..

Proof of policy must be provided

 no. In which case, my child must be covered by the EFSR’s liability insurance (see the C-2 point of rules of
procedures) and I agree to pay the insurance policy price per child as specified in the financial regulation for the
current year.

11. Hospitalisation in case of accident

In case of emergency at school or during a field trip, the procedure is as follows:
1. We call the parents (or the person specified in point 5) to inform them.
2. If we cannot get hold of any of the specified emergency contacts, we drive your child, in an ambulance
to: ANGKOR HOSPITAL FOR CHILDREN,

or the hospital of your choice. Please specify: …………………………………………………………………………………………

Parent’s signature: ................................................................................................................

 To submit at the school
12. Medical survey
To help to prevent any accidents or medical issues in the school for your child, please complete the form below:

Blood group of your child (if known): ........................

Does your child have a particular health problem? (Cardiac, respiratory, neurological, etc.):

If yes, please give details:

Does your child have any allergies? (Generic medicines, insect bites, food, etc.):

If yes, please give details:

Does your child have any disease which can need an immediate medical response? (Asthma, diabetes, epilepsy,
convulsions, etc.)

If yes, please give details:

13. Vaccinations and medical inspection

MANDATORY HIGHLY RECOMMENDED OPTIONAL

- HEVAC B (Hepatitis B)

- TETRACOQ (Diphtheria, Tetanus, - Meningitis Haemophilus (Hib), - Meningitis A and C

Pertussis, Polio)
- Rabies - HEVAC A (Hepatitis)
- BCG (Tuberculosis vaccination)
- MMR (Measles, Mumps, Rubella) - Encephalitis B
- anti-tuberculosis control (also called Japanese
- TYPHIM VI (Typhoid) Encephalitis)

Parent’s signature: ................................................................................................................

 To submit at the school
The Institution may require, at the time of enrolment or re-registration of a child, the vaccine certificates for the
first three vaccines qualified as “MANDATORY”

A medical examination will be organised during the school year for all students. The date and name of the doctor
will be communicated to parents at a later date.

 I agree that my child may be examined by a doctor

 I don’t agree that my child may be examined by a doctor

14. Acceptance of the rules of procedures

 By checking this box, I declare having acquainted with the rules of procedures of the school, accept and
fully understand it.

15. Acceptance of financial regulation

 By checking this box, I declare having acquainted with the financial regulation of the school, accept and
fully understand it.

Parent’s signature: ................................................................................................................