N.C.A.S. Enrollment Form

New Caribbean American School Application for Admission

DOCUMENTS REQUIRED:
• Last report card / Dernier bulletin scolaire
• Medical records or inoculation record / Carnet de vaccination
• Birth Certificate or passport / Acte de naissance ou passeport
• 2 passport size photographs / 2 photos format passeport
STUDENT INFORMATION:
Student Name *

First Name Middle Name Last Name
Entering Year *
Entering Grade *
Gender *

Female Male
Date of Birth *

Month Day Year
Nationality *

Haiti Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact Information *

Emergency Contact Name
Emergency Contact Phone Number
Relationship	State / Province
Postal / Zip Code	Country

Educational Information
Last three (3) schools attended (in chronological order)
Grade *
School Name *
Year *
Grade *
School Name *
Year *
Grade *
School Name *
Year *

Which languages can the student understand, speak, read, and write? *

	Understands	Speaks	Reads	Writes	N/A
English
French
Spanish

What are the student's interests?
Was the student a member of any clubs at their previous school?
MEDICAL INFORMATION
NOTE:

If your child needs medications during school hours, it is important to keep in mind the following information.

All medication should be transported to the school by an adult and handed to the school nurse.

Your child should not carry his or her medication during school hours.

All prescription and nonprescription medication (including vitamins) given in school settings require written authorization from your child's doctor, as well as parent written consent. This is a requirement of the rules that school nurses must follow.

All medication must be brought to school in the original labeled container prepared by the pharmacy, doctor, or pharmaceutical company (i.e., no envelopes, foil, or baggies). The label should include the following:

Child's name
Name of medication
Dosage of medication to be given
Frequency of administration
Route of administration
Name of physician ordering medication
Date of prescription
Expiration date

Physician Contact Information

Physician Contact Name
Physician Contact Phone Number
Relationship	State / Province
Postal / Zip Code	Country

Does your child have or has your child had any of the following?

Asthma Cancer Heart Disorder Epilepsy Hepatitis Infections Diabetes Fainting Seizures Anxiety Depression Behavioral Problems Learning Problems Kidney Disorder Cerebral Palsy Blood Disorder Mental Disorder Vision Impaired Speech Impairments Hearing Loss AIDS or HIV None
Medical Concerns
Allergies

FAMILY INFORMATION:
Are either parents an alumni?

Mother Father Both Neither
Does this student have siblings at N.C.A.S.?
Mother's Name

First Name Middle Name Last Name
Place of Business
Occupation
Title
Mother's Mobile Phone Number - 1 *
Mother's Mobile Phone Number - 2
Mother's WhatsApp Phone Number
Mother's E-mail
example@example.com
Father's Name

First Name Middle Name Last Name
Place of Business
Occupation
Title
Father's Mobile Number - 1 *
Father's Mobile Phone Number - 2
Father's WhatsApp Phone Number
Father's E-mail

Signature Page
I CERTIFY THAT THE INFORMATION PROVIDED IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
Today's Date *

Month Day Year
Date
Email of person submitting this application
example@example.com
Type name of person submitting this application *
Signature of person submitting this application

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