Infant Admission Form
This form should be completed in BLOCK CAPITALS.
Please read the instruction sheet carefully before completing the form.
SECTION I (PERSONAL INFORMATION)
1. Name of Child ………………………………………………………………………………...
(First) (Middle) (Last)
2. Date of Birth ………………………………... 3. Citizenship …………………………
4. Religion ………………………………..
5. Address at which child resides:…………………………………………………………………
6. Telephone Number (s): ……………………………………………………………………
7. E-mail Address: …………………………………………………..
8. Pre-school child attended: …………………………………………………………………
9. Address of Pre-School: ……………………………………………………………………
10. Phone Number of Pre-School: ……………………………………
(A photocopy of the computerized birth certificate must accompany this form.)
Laventille Boys Government Primary School
Tousaint Trace, Old St. Joseph Rd., Laventille
Phone/Fax: 623-3996
E-mail: laventilleboys@gmail.com
Principal: Mr. Carel Lewis
Senior Teacher: Ms. Lyra Bonaparte

SECTION II (HEALTH INFORMATION)
12. Has the child been inoculated? Please tick ( ) one response. Yes ( ) No ( )
(If yes, then write all the information required below from the immunization card.)
Dates Dates
Diph/Tet. …………………… Polio ……………………
…………………… ……………………
…………………… ..………………….
…………………… ……………………
…………………… ……………………
Yellow Fever …………………… Measles/ Rubella …………………….
13. Has the child received treatment for any of the following? Please tick ( ) all that apply.
Asthma ( ) Scabies ( ) Nose Bleed ( )
Bronchitis ( ) Small Pox ( ) Heart Disease ( )
Fits ( ) Skin Disorder ( ) Rheumatic Fever ( )
14. Any others not listed above: ………………………………………………………………
15. Allergies (please state): ……………………………………………………………………

SECTION III (FAMILY INFORMATION)
16. Mother’s Name : ……………………………………………………………………………
Postal Address : ……………………………………………………………………………
…………………………………………………………………………….
Occupation : ………………………………………………………………………………..
Employer’s Address : ………………………………………………………………………
………………………………………………………………………
17. Father’s Name : …………………………………………………………………………….
Postal Address : …………………………………………………………………………….
…………………………………………………………………………….
Occupation : ………………………………………………………………………………..
Employer’s Address : ………………………………………………………………………
………………………………………………………………………
18. Guardian’s Name : …………………………………………………………………………
Postal Address : …………………………………………………………………………….
…………………………………………………………………………...
Occupation : ………………………………………………………………………………..
Employer’s Address : ………………………………………………………………………
………………………………………………………………………
19. In case of an emergency, please contact:
Name Phone Number
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

20. Name(s) of brother(s) attending the school:
Name Class
…………………………………………………………………………………………….
…………………………………………………………………………………………….
……………………………………………………………………………………………..
………………………………. …………………………………...
Date Signature of Parent / Guardian
PLEASE NOTE
 Completed application forms are to be returned to the Principal by Monday 9th March, 2015.
No application forms will be considered after this date.
 Application forms will not be accepted without the requested documents and signature affixed thereto.
The completion of this form is not a guarantee that the child would be admitted.
 Application forms with falsified information will be considered null and void.
 The completed application along with a passport size photograph must be returned by the Parent/Guardian of the
child who is to be considered for admission. The form must NOT be sent with a child.