Middle and High School Application form Application Code * Click here to get application code! Academic Session * Name of Student * First Middle Last Sex * Male Female State what language your child understands or speaks Address * Phone No * Age by September this year Date of Birth Current Class Current School Current School Address * Nationality Town of Residence SECTION B: Information on Parents/Guardian Please provide us with more information on the child's caregiver Father's Name * First Last Father's Occupation Phone No Fathers' Title * Mr. Mrs. Dr. Prof. Engr. Mother's Name * First Last Mothers' Title * Mr. Mrs. Dr. Prof. Engr. Mother's Occupation Phone No Parent's Place of Worship * Parent's Postal Address * Residential Address (if different from above) * YOUR CHILD'S HEALTH Please provide us with details about your child's health. For immunizations, tick the ones your child has received and the dates of each. Give name and address of your child’s physician * Emergency Phone Numbers * Parent's Email Address * MEDICAL FITNESS FORM Name of Student * First Middle Last Date of Birth * Father's Name * First Last Mother's Name * First Last Number of Siblings * Any family history of: Hypertension * Yes No Sickle Cell Disease * Yes No Epilepsy * Yes No Glaucoma * Yes No Have you ever been told you have: Asthma * Yes No Persistent Cough, Blood Spitting * Yes No Pneumonia * Yes No Tuberculosis * Yes No Sickle Cell Disease * Yes No Disorder of the Kidney * Yes No Brethlessness * Yes No Heart Disorder * Yes No Lice * Yes No Ring Worm * Yes No Hepatitis A * Yes No Hepatitis B * Yes No Hepatitis C * Yes No Hepatitis D * Yes No Others (Please Specify) Give the name and address of the doctor from whom you last received medical advice or treatment. Please state when and why. * I declare that the answers to the above questions are true and complete and that I have not withheld any information and I agree that the answers given to the separate questions in this form shall form the basis for my admission into Mount Carmel Christian School, Jos. I consent to the Coordinator/Principal seeking information from my physician or other person in regard to my health and I hereby authorize the giving of such information. Parent full name as signature to this document. * Date *
