Please complete this enrolment application for any international fee-paying students wishing to attend Te Ao Mārama School.

*Surname

Surname as it appears on passport

*First Name/s

First name/s as they appear on passport

Preferred Name

If different to above

*Date of Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2007 2008 2009 2010 2011 2012 2013 2014

DD/MM/YYYY

*Gender

• Male
• Female

*Address

Address in home country

*First Language

Language most commonly spoken at home

*Country of Citizenship

*Passport Number

*Passport Expiry Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

*Intended Start Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2019 2020 2021 2022

Date student would like to start at Te Ao Mārama School

*Intended Finish Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2019 2020 2021 2022

Date student would like to finish at Te Ao Mārama School

Relationship to Student

• Father
• Mother
• Legal Guardian

Please also complete 'Parent 2' section if possible

Title

• Mr
• Dr
• Mrs
• Miss
• Ms

*Surname

*First Name

*Date of Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

*Home Address

Postal Address

If different to above

*Mobile Number

Home Contact Number

Work Contact Number

*Email Address

*First Language

*Country of Citizenship

*Passport Number

*Passport Expiry Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Relationship to student

• Father
• Mother
• Legal Guardian

Title

• Mr
• Dr
• Mrs
• Miss
• Ms

Surname

First Name

Date of Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Home Address

Postal Address

If different to above

Mobile Contact Number

Home Contact Number

Work Contact Number

Email Address

First Language

Country of Citizenship

Passport Number

Passport Expiry Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

*First Name and Surname

An emergency contact in the student's home country, other than parents)

*Mobile Contact Number

Home Contact Number

*Email Address

Agency Name

If you are using an International Agent, please complete this section

Agent Name

Agent Email Address

Agent Contact Number

*Name of Doctor

Name of student's regular Doctor in home country

*Doctor Contact Number

*Does the student have any history of previous illness that may affect their enrolment, including mental illness?

• Yes
• No

If 'Yes', please provide more information below

*Medical Conditions

• Asthma
• HIV or Aids
• Tuberculosis
• Depression/Anxiety
• Back or Neck Problems
• Diabetes
• ADD or ADHD
• Glandular Fever
• Hepatitis A, B or C
• Allergies
• Food Allergies
• Epilepsy
• Migraines
• Heart Condition
• Eating Disorder
• None of the Above

Please select any medical conditions that the student has or does suffer from. More details can be provided below.

Medical Information

If answered 'yes' above or selected any of the medical conditions, please provide as much information as possible here

*Does the student have any medical implants (such as metal implants) that may affect receiving medical treatment while in New Zealand?

• Yes
• No

*Is the student currently on any medication?

• Yes
• No

If 'Yes', please detail below

Medication

Please detail any current medication the student is taking

*Is there anything further that the school needs to be aware of that may impact the suitability of the student as an international student?

• Yes
• No

If 'Yes', please detail below

Further Information

If 'Yes' was selected above, please detail

*Does the student have any learning or behavioural difficulties requiring extra school support or services?

• Yes
• No

If 'Yes', please provide more information below

Learning / Behavioural Information

If you selected 'Yes' above, please provide more information

*Has the student previously applied for entry to Te Ao Mārama School?

• Yes
• No

*Has the student ever had a family member enrolled at Te Ao Mārama School?

• Yes
• No

If 'Yes', please detail below

Family Member

If answered 'Yes' above, please detail family member's name and year attended

*Has the student previously studied at any other New Zealand school?

• Yes
• No

If 'Yes', please detail below

Previous NZ School

If 'Yes' answered above, please detail name of school and dates attended

*How long has the student studied English?

Please detail Months and Years

*Do the student's parents speak English?

• Yes
• No

*Do the student's parents read English?

• Yes
• No

*Accommodation Choice

• Homestay
• Designated Caregiver
• Live with Parent

Designated Caregiver means a relative or family friend

Student Interests

• Music
• Movies / TV
• Reading
• Outdoor Activities
• Water Sports
• Travel

Other Interests

Please note any other interests the student has

Name of Caregiver

If student will be staying with a relative or family friend, please complete this section

Address in New Zealand

Email Address

Relationship to student

eg: Uncle, Aunty, Cousin, Grandparent, Family Friend

*Do you wish to purchase insurance through Te Ao Mārama School?

• Yes
• No

If 'Yes', please select which provider you would prefer

• Southern Cross
• Uni-Care
• Other
• No Preference

Own Insurance Provider

If you are arranging your own insurance, please provide name of the provider

Insurance Policy Number

Insurance policy start date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2019 2020 2021 2022

Insurance policy end date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2019 2020 2021 2022

Please provide a copy of your insurance policy in English

This form needs to be completed in conjunction with the following declarations (where applicable):
1. Parents/Legal Guardians' Declaration and Authorisation
2. International Student Accommodation Agreement (if student is staying in school approved homestay)
3. Designated Caregiver Agreement (if student is staying with a relative or family friend)

These declarations can be found on the 'Enrolment Declarations' page under the International Students tab