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Please fill in your personal data here! Fields marked with * are required.

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Date*

Child's Information

First Name*

Family Name*

Gender* Boy Girl

Date of Birth*

Nationality*

Religion*

Year of Entry*

Term of Entry* Term 1 Term 2 Term 3 Term 4

Please choose which group are you applying for* Early Years Junior School Senior School Sixth Form

Parent's Information

Father's Details

Father's Name*

Address*

Company Name*

Designation/Position*

Phone Number (Home)

Phone Number (Office)

Mobile Number*

E-mail*

Mother's Details

Mother's Name*

Address*

Company Name

Designation/Position

Phone Number (Home)

Phone Number (Office)

Mobile Number*

E-mail*

Address of Child (if different from above)

How did you hear about Repton Malaysia?* Social Media Advertising Online Search Reference Others (Please write on the space provided below)

Have you registered your child at any other school and, if so, where?*

Please mention the names of any other members of the family attending Repton School or who are registered

for admission, please mention any other connection with the School.

Write your answer here.

Please state the name and address of each school (with dates) attended in the last three years, current school

first, together with the name of the head teacher.

Name of School / Headteacher / Email

Curriculum

Class/ Grade

Please provide us with details of any medical condition (including allergies), disabilities or learning difficulties of your child. Has your child ever been diagnosed with any of the following? You must disclose any factor which may affect your child's ability to cope independendy within the mainstream school environment. If your child has learning difficulties and has an IEP, this must be presented as part of the application. Failure to disclose any learning difficulties or medical conditions at the time of application may result in withdrawal of the application. Any offer made by the school is subject to its ability to meet the individual needs of the child.

Dyslexia Language/Speech Disorders Emotional or behavioural difficulties Dyscalculia DD/ADHD Dyspraxia Autism Spectrum Learning Difficulties

Is your child currendy taking any medication? If yes, please give detail...*

Has your child ever received any support in a special educational programme such as learning difficulties or speech therapy? If yes, please give detail...*

Has your child ever been suspended from school or been expelled? If yes, please give detail...*

Has your child ever been asked to leave a school? If yes, please give detail...*

Does your child have any allergies or food intolerance? If yes, please give detail...*

Does your child have an Epipen?*

For Non-native English speakers

Child's First Language?*

Child's Second Language?*

Other Languages spoken?

Main Language spoken at home?*

Is English used at home?* Yes No

Please outline any of your child's artistic, dramatic, musical or sporting skills or experience if applicable

and I or hobbies and interests.

Artistic

Sport

Drama/Music

Others

Any additional information? Please state here...

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