Enrolment & Learner Information

Mosaic Remedial

Enrolment & Learner Information Form

Pre-School: 6 Months – Grade RR | Tutor Centre: Grade R – Grade 12

Principal / Owner: Petro Potgieter • Tel/WhatsApp: 064 903 4129 •

Joos Williamson Rd & Rachel De Beer St, Kookrus, Meyerton, 1961

Confidential Learner Information

Please complete all applicable sections. The information supplied assists Mosaic in understanding and safely supporting each learner’s educational, developmental, medical, emotional and therapeutic needs. Please attach relevant reports where available.

1. Learner's full name and surname *
Preferred name / nickname
Date of birth *
Age
South African ID / Birth Certificate No.
Gender
Home language
Other language(s)
Nationality
Residential address
2. Programme	Pre-School – 6 months to Grade RR Tutor Centre – Grade R to Grade 12
Grade / age applying for
Preferred starting date
Attendance	Half Day Full Day
Main reason for enrolment	Small learning environment Individual attention Remedial support Academic support Learning barriers Attention / concentration Behavioural support Emotional support Social difficulties Reading difficulties Spelling / writing difficulties Mathematics difficulties Language / speech concerns Sensory needs Developmental concerns Autism support ADHD / ADD support Dyslexia support Online schooling support Homework support
Please explain
3. Parent / Guardian 1 – Full name
Relationship to learner
ID number
Cell / WhatsApp
Email
Occupation / Employer
Parent / Guardian 2 – Full name
Relationship to learner
ID number
Cell / WhatsApp
Email
Occupation / Employer
Custody / legal order affecting learner:	No Yes – supporting documentation attached
Details
4. Authorised Persons for Collection — Name & surname / Relationship / Contact number / ID / notes
	I understand that Mosaic may request identification and will release the learner only to an authorised person.
5. Primary emergency contact – name
Relationship
Cell number
Alternative number
Secondary emergency contact – name
Relationship
Cell number
Alternative number
6. Medical aid provider
Medical aid number
Main member
Main member ID
Doctor / GP
Doctor contact number
Paediatrician (if applicable)
Paediatrician contact number
7. Medical History	Asthma Epilepsy / seizures Diabetes Heart condition Respiratory condition Severe allergies Food allergies Medication allergies Skin condition / eczema Hearing problems Vision problems Frequent headaches / migraines Fainting / loss of consciousness Serious infections Recent hospitalisation Operations / surgery Significant injuries Chronic illness Other
For each applicable condition, provide details, dates, treatment and emergency instructions:
8. Allergies	No known allergies Food allergies Environmental allergies Medication allergy Latex allergy Insect allergy Other
Known allergens:
Reaction / symptoms:
Emergency treatment / medication:
	Allergy / anaphylaxis action plan attached.
9. Medication / Reason / Dosage / Time / frequency / Administration instructions
Medication	Prescription / doctor's instructions attached. No regular medication.

10. Pregnancy:	Normal / uncomplicated High risk Complications
Birth:	Full term Premature Post-term
Delivery:	Natural / vaginal Caesarean Assisted delivery
Gestational age (weeks)
Birth weight
NICU admission / duration
Birth complications
Developmental concerns:
11. Developmental Milestones – delayed / concern	Head control Sitting Crawling Walking Running Fine motor skills Speech development Understanding language Toilet training
Details / age achieved
12. Diagnoses & Learning Barriers	ADHD ADD Autism Spectrum Disorder Dyslexia Dyscalculia Dysgraphia Dyspraxia / developmental coordination difficulties Speech / language disorder Language delay Developmental delay Intellectual / developmental disability Sensory processing difficulties Specific learning disorder Emotional / behavioural difficulties Other
Diagnosis / concern
Date diagnosed / identified
Professional who diagnosed
Profession / contact details
Reports	Diagnostic report attached. No report currently available. Currently being assessed.
13. Previous Assessments	Academic School readiness Educational psychology Psychological Occupational therapy Speech / language Audiology Optometry Paediatric Neurological Behavioural Emotional Other
Date of most recent assessment:
Main findings / recommendations:
	Relevant reports attached.
14. Therapy & Professional Support – currently receiving	Occupational Therapy Speech Therapy Physiotherapy Psychology / Counselling Remedial Therapy Educational Psychology Kinderkinetics Psychiatry / Paediatrician
Previous therapy
Professional / practice
Current therapeutic goals / recommendations:
15. Current / previous school
Current grade
Years attended
Grade repetition (if any)
Areas of concern	Reading Phonics Spelling Writing Handwriting Mathematics Problem solving Comprehension Language Memory Concentration Organisation Homework Study skills
Other academic concerns:
16. Executive Function, Motor & Perceptual Support	Attention Concentration Memory Planning Organisation Time management Following instructions Task completion Impulse control Fine motor Gross motor Handwriting Visual perception Visual-motor integration Spatial awareness Coordination
17. Child's temperament	Calm Active Sensitive Shy Confident Sociable Anxious Easily frustrated Impulsive Strong-willed
Behavioural concerns	Aggression Tantrums Withdrawal Anxiety Separation difficulties Defiance Impulsivity Difficulty following rules Difficulty sharing Difficulty making friends Emotional outbursts Self-regulation difficulties Other
Triggers:
What helps the learner calm down?
Strategies that work well / should be avoided:
18. Sensory sensitivities:	Sound Touch Visual Movement Food / oral Clothing / texture
Speech / communication concerns:	Pronunciation Understanding instructions Expressing needs Vocabulary Sentence formation Social communication Stuttering Alternative communication
Details:

19. Daily Living, Nutrition & Sleep	Toileting assistance Dressing assistance Eating assistance Drinking assistance Personal hygiene Packing belongings Picky eating Texture difficulties Choking risk Special diet Difficulty falling asleep Night waking Night terrors Difficulty waking
Dietary requirements / foods that must NOT be given:
Typical bedtime / waking time:
20. My child's strengths:
Interests	Art Music Animals Sport Reading Building Computers / technology Outdoor activities Crafts Dancing Drama Puzzles Games Other
Parent / guardian goals for enrolment:
Other concerns or information Mosaic should know:
21. I authorise Mosaic staff to obtain appropriate emergency medical assistance for my child when reasonably necessary.	I agree I do not agree
Preferred emergency medical facility (if applicable):
22. Medication	I understand Mosaic's medication procedure. I will provide written medication instructions. I will notify Mosaic of medication changes.
I give permission for Mosaic to communicate with relevant professionals involved in my child's support:	Occupational Therapist Speech Therapist Educational Psychologist Psychologist / Counsellor Paediatrician / Doctor Physiotherapist Previous / Current School Other
23. Assessment & Support Consent	I consent to appropriate educational / developmental / remedial screening. I understand assessment results may be discussed with me. I understand referral may be recommended where additional support is indicated.
24. Photography & media consent – please indicate your preference:	YES – educational / promotional use NO – promotional use
25. Documentation Checklist	Completed enrolment form Learner birth certificate / ID Parent / guardian ID Medical aid information Immunisation record (where applicable) Previous school report Assessment reports Diagnostic reports Occupational therapy report Speech therapy report Psychological / educational psychology report Medical / paediatric report Medication instructions Allergy / emergency action plan Individual Support Plan (if applicable) Other
Attach supporting documents	Max file size (Mb): 10
26. Parent / Guardian Declaration	Information supplied is accurate Relevant reports have been disclosed I will notify Mosaic of material changes I have read and understood this form I agree to applicable Mosaic policies
Parent / Guardian 1 – full name
Parent / Guardian 2 – full name
Signature
Signature
Date
Date

Thank You

Thank you for taking the time to complete the enrolment form. We appreciate the trust you place in Mosaic Remedial and will be in touch shortly. If you have any questions, please contact us on 064 903 4129.