ពាក្យសុំចូលរៀន Application Form

APPLICATION STUDENT:

Last-First Name
Date of Birth
Place of Birth
First Language
​ Nationality
Religion
​ Gender:
Age at Entry
School Year:
Program Applied for:
Full Day
Half Day
Grade:
Home Address:
PARENTS:

Father’s Name
Home Tel
Home Email
Occupation

Mother’s Name
Home Tel
Home Email
Occupation
ACADEMIC PROFILE:

Child’s Current Form/Year/Grade Before IUIS Entry

Scholastic Standing:
In Advance of Age
Up to Standard for Age
Below Standard

Is There Any Evidence of any Learning Difficulty?
No Yes
( attach full explanation)


No Yes
( attach full explanation)

Previous School(s) Attended

Reason for Withdrawal From Present School:
INTERESTS:

Favourite Sports (specify ifon a school Team)

Interests and Hobbies

Musical Instrument

List Any Awards Achieved
HEALTH AND PHYSICAL SUMMARY:
Does the Student Have any:
Allergies?
No
Asthma:
No
Yes
Epilepsy:
No
Yes
Diabetes:
No
Yes
Heart Condition:
No
Yes
Obesity:
No
Yes

Knee, ankle, ligament or back problems:
No
Yes

Physical or mental disabilities:
No
Yes

Emotional problems or depression:
No
​ Yes

History of anorexia or bulimia:
No
​ Yes

Frequent recurring illnesses:
No
​ Yes

Has the student had any accidents or operators?
No
Yes

Is the student taking any general medication?
No
Yes
If YES, give details:
If YES, give details:
Any other medical comments:
OTHER INFORMATION:
IUIS
I Heard About IUIS Through:
Friend
Publication/Ad
Educational Consultant
Another School
Other (website, etc)

Student’s Passport Number
Country
Expiry Date

Does the student currently hold a health insurance plan?
Friend
Yes
ALTERNATIVE EMERGENCY CONTACT:

Person to be contacted in an emergency, should we be unable to contact the parent(s) named over leaf:
Name
Telephone
Email
Relationship to the Child
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