Office use only

Ecole de L’Assomption registration date : …..…………………

Office use only

Année scolaire : ………………………………………………

N° matricule ………………………………………………………..

N° xxxxxx ……………………………………………………………..

Classe ………………………………….

00 xxx Xxxx Xxxxxxxxx 00000 Xx Havre

02 35 43 60 68

Régime : …………………………………….

Garderie : ……………………………………

Instalment : 45€ deducted from the 1st invoice (non refundable)/1 book of 10 stamps/child’s health report/birth certificate or passport

Last name : ………………………………………………………………

First name : ……………………………………………………..

Date of birth : ………………………………………………..

Place of birth…………………………………………………………

Marital status : married /single/cohabitation /divorced/widow/separated

Parents’ address :

..………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………… Home phone number: ……………………………………………..

Mobile phone number: ……………………………………………. / ……………………………………………….

Professional phone number ………………………………………….

Email: …………………………………………………………………………

Total of children: …………… Total of school age children ………………………

Insurance : ………………………………………………………………

Direct debit (bank account details needed)

Health information

Does your child wear glasses? Permanently / Only in class

Does your child have a disease that needs a permanent medical treatment? Food allergy : …………………………… Special diet : …………………………………………

Special needs (not in school)

Speech therapy / psychologist

/

…

Lunch invoice

Never

Every day

Regularly : Monday / Tuesday / Thursday / Friday

Childminding invoice

Morning 7.45-8.15 am /

Evening 4.45-5.55 pm

I , , give to the headmistress the permission to

make a decision concerning my child, in case of emergency, for the transportation to hospital or surgery if I cannot be reached.

Signature

My child may have his/her picture taken or be filmed during school activities.

I agree

/ I don’t agree

Signed on ……………………………………………………., in ………………………………………………

Signature