Southbrook Academy Enrollment Form

3334 Sitio Pungsod
Lawaan III, Talisay City, Cebu

Phone 09272332137/09397581595/5134106

As a good and cooperative member of Southbrook Academy, Inc. Educating Community, I promise to abide by the rules and regulations of Southbrook Academy, Inc. I also understand that my failure to cooperate with the school towards the integral formation of my child would lead to the forfeiture of his/her slot in th school for the following school year.

    [md-form]

    [md-text label="Learner Reference Number (LRN)"]

    [/md-text]

    [md-text label="Full Name"]

    [/md-text]

    [md-text label="Email"]

    [/md-text]

    [md-text label="Phone Number"]

    [/md-text]

    [md-select label="Select Gender"]

    [/md-select]

    [md-text label="Date of Birth"]

    [/md-text]

    [md-text label="Place of Birth"]

    [/md-text]

    [md-text label="Age"]

    [/md-text]

    [md-text label="Nationality"]

    [/md-text]

    [md-text label="Religion"]

    [/md-text]

    [md-text label="Birth Rank (Min Value of 1)"]

    [/md-text]

    [md-text label="Student Home Address"]

    [/md-text]

    [md-text label="Street Address"]

    [/md-text]

    [md-text label="Address Line 2"]

    [/md-text]

    [md-text label="City"]

    [/md-text]

    [md-text label="State/Province"]

    [/md-text]

    [md-text label="Postal/Zipcode"]

    [/md-text]

    [md-text label="Country"]

    [/md-text]

    [md-select label="Educational Alternative" help= "Please review the Agreement accessible from the Download button above"]

    [/md-select]

    [md-text label="Mother's Maiden Name"]

    [/md-text]

    [md-text label="Mother's First Name"]

    [/md-text]

    [md-text label="Mobile Number"]

    [/md-text]

    [md-text label="Mother's Occupation"]

    [/md-text]

    [md-text label="Mother's Position"]

    [/md-text]

    [md-text label="Street Address"]

    [/md-text]

    [md-text label="Address Line 2"]

    [/md-text]

    [md-text label="City"]

    [/md-text]

    [md-text label="State/Province"]

    [/md-text]

    [md-text label="Postal/ Zipcode"]

    [/md-text]

    [md-text label="Country"]

    [/md-text]

    [md-text label="Mother's Email Address"]

    [/md-text]

    [md-text label="Work Number"]

    [/md-text]

    [md-text label="Father's Maiden name"]

    [/md-text]

    [md-text label="Father's First Name"]

    [/md-text]

    [md-text label="Mobile Number"]

    [/md-text]

    [md-text label="Father's Occupation"]

    [/md-text]

    [md-text label="Father's Position"]

    [/md-text]

    [md-text label="Street Address"]

    [/md-text]

    [md-text label="Address Line 2"]

    [/md-text]

    [md-text label="City"]

    [/md-text]

    [md-text label="State/Province"]

    [/md-text]

    [md-text label="Postal/ Zipcode"]

    [/md-text]

    [md-text label="Country"]

    [/md-text]

    [md-text label="Father's Email Address"]

    [/md-text]

    [md-text label="Work Number"]

    [/md-text]


    [md-select label="Outlined select"]

    [/md-select]


    [md-text label="Full Name"]

    [/md-text]

    [md-text label="Primary Contact Name"]

    [/md-text]

    [md-text label="Primary Contact Phone Number"]

    [/md-text]

    [md-text label="Secondary Contact Name"]

    [/md-text]

    [md-text label="Secondary Contact Phone Number"]

    [/md-text]


    [md-checkbox label="Allergic Reaction to"]
    Cat HairDustPollenFoodMoldOtherNo Allergies
    [/md-checkbox]

    [md-textarea label=" If Food or Other Please Specify"]

    [/md-textarea]


    [md-textarea label="Please Specify Current Medication"]

    [/md-textarea]

    [md-checkbox label="If the child gets sick what medicine(s) should the nurse or teacher administer?"]
    BiogesticParacetomolTempraOther
    [/md-checkbox]

    [md-textarea label=" If Other Please Specify"]

    [/md-textarea]

    [md-text label="Name of Guardian"]

    [/md-text]

    [md-text label="Relationship to the Student"]

    [/md-text]

    [md-text label="Pesos"]

    [/md-text]

    [md-text label="Cents"]

    [/md-text]

    [md-file label="Please attach a copy of the receipt" help="png,jpg,pdf"]

    [/md-file]

    [md-text label="Accomplished By"]

    [/md-text]

    [md-text label="Date"]

    [/md-text]

    [md-accept label="PROCESS COMPLETION: By checking the box below you will agree to the terms and you will initiate the 2500php payment process on PayPal. If you are paying by a different method, you can just ignore the PayPal redirect." terms="I have read and agree to the Terms & Conditions between Parents and School"]

    [/md-accept]

    [md-submit]

    [/md-submit]
    [/md-form]