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APPLICATION FORM
STUDENT INFORMATION (Please write in capital letters!)
First Name(s) (please underline name used)
GUARDIAN(S) INFORMATION
Guardian 1
Guardian 2
 Please tick if you are the child’s only guardian Square d'Argenteuil 5, B-1410 Waterloo, Belgium STUDENT INFORMATION
Has the student had any type of learning support previously?  Yes  No Specific information which is important for the student’s education: special needs, medication etc. The student has studied French: The student has brothers/sisters at BIS: How did you get information about our school?  From current School  From a friend  Advertising  Website Other:…………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… IMPORTANT INFORMATION BEFORE YOU DO YOUR APPLICATION!

Please enclose the following with the application:
To be provided by the current school:
Letter of motivation (in English) explaining why you

Scandinavian School of Brussels
Square d'Argenteuil 5, B-1410 Waterloo, Belgium RULES OF PAYMENTS:
The annual fee for the coming school year is set in May at SSB’s general assembly. A registration fee of 650€ is a one-time fee to be paid at the time of application for each new student at SSB. This fee will not be repaid if the student does not decide to attend the school. However, if the school cannot offer a place for the student, the fee is repaid. The school fee is for a full school year. The fee is divided in to two different payments: 60% for payment at the latest June 15 and 40% for payment at the latest November 15. New students pay their fees, at the latest, 10 days before they start. Students who begin at SSB after the start of the school year are given a reduction according to the following principles: Students who begin after November 1 pay 85%, after January 1 pay 60%, and after March 1 pay 45% of the yearly fee. Students who leave the school during the school year should, in order to earn a reduced fee, inform the school of their intentions before the school year starts. Students who leave after November 1 or April 1 will not be given a reduction. Students who have not paid their fees according to the rules above have no right to start at the school. The school uses interest fees for past overdue payments. If the school is forced to follow-up the overdue payments, the parents must bear the costs incurred. Invoices will be paid (please cross one) The signature(s) below indicates that you accept the rules above and agree to the responsibility of payment of fees and agree to keep SSB updated of all changes in the contact details. Square d'Argenteuil 5, B-1410 Waterloo, Belgium ADMINISTRATION (For administration only)
Square d'Argenteuil 5, B-1410 Waterloo, Belgium HEALTH RECORD
THIS INFORMATION WILL BE KEPT CONFIDENTIAL
Surname of student: ____________________________
Sex: ________ Grade: ______________________________ First / middle name: ____________________________ Date of birth: _____/______/__________________________ (Day) (Month) (Year) Address:______________________________________ Email:____________________________________________ GSM Number mother: ___________________________ Office number: _____________________________________ GSM number father: ____________________________ Office number: _____________________________________ Family doctor (Belgium):_________________________ Tel.number:________________________________________ Family dentist (Belgium):_________________________ Tel. number: _______________________________________ IMMUNIZATION HISTORY FILL IN DATES GIVEN REMARKS:
Diphtheria/ Pertussis/ Tetanus
Last physical check: ____________________________ Last hearing test:__________________________________ Result: _______________________________________ Last vision test: ____________ Result: ________________ Colorblind: ____________________________________ Does your child wear glasses/contact lenses? YES / NO Serious injuries: ________________________________________________________________________________________ Does your child have sport limitations: YES / NO Specify: _______________________________________________________ Has your child had surgery: YES / NO Specify: ________________________________________________________________ Hospitalizations: ________________________________________________________________________________________ Specify: _______________________________________________________________________________________________ Has your family members had any serious illnesses? Father: _______________________________________________________________________________________________ Mother: _______________________________________________________________________________________________ Brothers or Sisters: ______________________________________________________________________________________ Square d'Argenteuil 5, B-1410 Waterloo, Belgium
Has your child had, or been recommended to have:
a) Speech therapy: ______________________________________________________________________________________
b) Psychological counseling: ______________________________________________________________________________
Do you have any other information you feel should be made known to the school in the interest of the child:
Specify________________________________________________________________________________________________
HEALTH/ CHILDHOOD HISTORY:
Concussion
Headaches /Dizziness/Fainting
Epilepsy
Asthma / Eczema/ Hay fever
Allergies
Medical allergies
Diabetes
Heart problems / murmur
Rheumatic fever
Bone / joint injury
Chronic illness or condition
Ear tubes/ENT problems
Tonsillectomy
Adenoidectomy
Sleep problems: Nightmares,
bedwetting
Chickenpox
Scarlet fever
Whooping cough
Eating disorders
CURRENT MEDICATION:

I give permission to administer, if necessary, PARACETHAMOL / IBUPROFEN / COLD MEDICIN YES / NO
IF YES; PLEASE SIGN HERE: ____________________________________________________________________________
(Parent/Guardian)

All prescription medications need a written note from parents/guardian. All Medications must be submitted to the form teacher or
the school nurse. Medications must be in original containers, marked with name, dose and if needed instructions.

I approve that my child may be given Emergency Medical treatment if required.
Date: ____________________________Signature:____________________________________________________________

IN CASE OF ACCIDENT OR ILLNESS- if parents cannot be reached, PLEASE NOTIFY:

Name:___________________________________________
Tel. nr:____________________________________________

GSM:____________________________________________
Office nr:__________________________________________

Address:______________________________________________________________________________________________

Square d'Argenteuil 5, B-1410 Waterloo, Belgium

Source: http://www.4suppdatera.se/4suploads/61072/dokument/2012-2013_day-student-IB-final.pdf