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+1 (345) 943-7323

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*=Required

STUDENT INFORMATION

Student Legal Name*:
Student Preferred Name*:
Date of Birth*:
Gender*: Male Female
Registration for Year (Yr4- Yr9)*:
Proposed Start Date*:
Nationality (or passports held)*:
Caymanian*: Yes No
Current Grade/Year (Indicate if British or American system)*:
Name and address of each school Year/ Grade From To
Had your child ever repeated a year/ grade?: Yes No
If yes, which year/ grade was repeated?:
Where:
Has your child ever received Special Education or Learning Support?: Yes No
If so, please provide details of extra help given and provide specialist reports:
Does your child receive or require Counselling support?:  Yes No
If so, please provide details:
The following documents should accompany this form where applicable Yes/No File Comments
School reports – last report and previous end of year report
Copy of Birth certificate/ Passport page
Education Psychologist/ Neuropsychologist report
Speech and Language
Occupational Therapy
Arrowsmith Suitability Checklist Download
Immunisation Record
Other
How did you hear about CLC:
Is your child's first language English?: Yes No

PARENTS INFORMATION

Indicate Primary Caregiver: Mother/ Father/ Guardian/Other*:
Mother's Name*:
Street Address*:
District*:
PO Box*:
Postal Code*:
Phone Work*:
Cell*:
Email:
Place of Employer:
Profession:

FATHER INFORMATION

Father Name*:
Street Address*:
District*:
PO Box*:
Postal Code*:
Phone Work*:
Cell*:
Email:
Place of Employer:
Profession:

STUDENT RELEASE INFORMATION

Name*:
Phone:
Relation:
Name:
Phone:
Relation:
Please indicate if there is a court order restricting access to this child: Yes No
If so, indicate individuals name:

STUDENT MEDICAL HISTORY

Doctor's Name:
Doctor's Phone:
Doctor's Address:
Please list all medical history:
Please list any allergies or medication:

Parent Declaration

I hereby declare that I have read and understood the information contained on this form, including the attached policies and procedures form, and agree with all of Cayman Learning Centre’s Policy and Procedures. I understand that my child will be required to participate fully in programmes and adhere to centre/ school rules and policies. I agree that all parents/ guardians/ caregivers involved will do their upmost to cooperate fully with the school in its rules and policies. I understand there is a licensing fee that covers the cost of the assessment and one cognitive enhancement programme. This fee is due with submission of this form and is non-refundable. I also understand that this does not include the monthly fee for time spent with the Arrowsmith teacher.

The information I have provided is correct.

Signed (Parent/ Guardian):
Dated:
 I consent that pictures and/or videos taken of my child may be used for CLC promotional purposes only.
 I consent to receiving newsletters.
Accept Terms of Policy and Procedures*:  Yes, I Accept.

Terms & Conditions.

Cayman Learning Centre
Cayman Learning Centre